Variability of corticospinal and spinal reflex excitability for the ankle dorsiflexor tibialis anterior across repeated measurements in people with and without incomplete spinal cord injury

To adequately evaluate the corticospinal and spinal plasticity in health and disease, it is essential to understand whether and to what extent the corticospinal and spinal responses fluctuate systematically across multiple measurements. Thus, in this study, we examined the session-to-session variability of corticospinal excitability for the ankle dorsiflexor tibialis anterior (TA) in people with and without incomplete spinal cord injury (SCI). In neurologically normal participants, the following measures were obtained across 4 days at the same time of day (N = 13) or 4 sessions over a 12-h period (N = 9, at 8:00, 12:00, 16:00, and 20:00): maximum voluntary contraction (MVC), maximum M-wave and H-reflex (Mmax and Hmax), motor evoked potential (MEP) amplitude, and silent period (SP) after MEP. In participants with chronic incomplete SCI (N = 17), the same measures were obtained across 4 days. We found no clear diurnal variation in the spinal and corticospinal excitability of the TA in individuals with no known neurological conditions, and no systematic changes in any experimental measures of spinal and corticospinal excitability across four measurement days in individuals with or without SCI. Overall, mean deviations across four sessions remained in a range of 5-13% for all measures in participants with or without SCI. The study shows the limited extent of non-systematic session-to-session variability in the TA corticospinal excitability in individuals with and without chronic incomplete SCI, supporting the utility of corticospinal and spinal excitability measures in mechanistic investigation of neuromodulation interventions. The information provided through this study may serve as the reference in evaluating corticospinal plasticity across multiple experimental sessions.

Methodological considerations on near-infrared spectroscopy derived muscle oxidative capacity

PURPOSE

Different strategies for near-infrared spectroscopy (NIRS)-derived muscle oxidative capacity assessment have been reported. This study compared and evaluated (I) approaches for averaging trials; (II) NIRS signals and blood volume correction equations; (III) the assessment of vastus lateralis (VL) and tibialis anterior (TA) muscles in two fitness levels groups.

METHODS

Thirty-six participants [18 chronically trained (CT: 14 males, 4 females) and 18 untrained (UT: 10 males, 8 females)] participated in this study. Two trials of twenty transient arterial occlusions were performed for NIRS-derived muscle oxidative capacity assessment. Muscle oxygen consumption ([Formula: see text]O2m) was estimated from deoxygenated hemoglobin (HHb), corrected for blood volume changes following Ryan (HHbR) and Beever (HHbB) equations, and from oxygen saturation (StO2) in VL and TA.

RESULTS

Superimposing or averaging [Formula: see text]O2m or averaging the rate constants (k) from the two trials resulted in equivalent k values [two one-sided tests (TOST) procedure with 5% equivalence margin-P < 0.001]. Whereas HHbR (2.35 ± 0.61 min-1) and HHbB (2.34 ± 0.58 min-1) derived k were equivalent (P < 0.001), StO2 derived k (2.81 ± 0.92 min-1) was greater (P < 0.001) than both. k values were greater in CT vs UT in both muscles (VL: + 0.68 min-1, P = 0.002; TA: + 0.43 min-1, P = 0.01).

CONCLUSION

Different approaches for averaging trials lead to similar k. HHb and StO2 signals provided different k, although different blood volume corrections did not impact k. Group differences in k were detected in both muscles.

Footedness but not dominance influences force steadiness during isometric dorsiflexion in young men

The aim of the study was to assess the potential influence of footedness and dominance on maximal force, force fluctuations and neural drive during dorsiflexion. Fifteen left-footed (LF) and fifteen right-footed (RF) young adults performed 2 maximal voluntary contractions (MVC) and 3 steady submaximal isometric contractions at five target forces (5, 10, 20, 40 and 60% MVC) with the dorsiflexors of both legs. High-density electromyography (EMG) was used to record the discharge characteristics of motor units (MUs) of Tibialis Anterior. MVC force and EMG amplitude (root mean square) were similar between the two legs and groups (p > 0.05). Force fluctuations (Coefficient of Variation, CoV for force), mean discharge rate of MUs, discharge variability (CoV of interspike interval), and variability in neural drive (standard deviation of filtered cumulative spike train) were greater (p < 0.05) and the input-output gain of the MUs (ΔDR/ΔF) was lower (p < 0.05) for the LF relative to the RF group. The differences in force fluctuations during steady contractions with the dorsiflexors were associated with footedness but not with dominance. They reflect greater variability in motor neuron output, as suggested by coefficient of variation for interspike interval (independent input) and the standard deviation of the smoothed discharge times (common input).

The role of intraoperative extensor digitorum brevis muscle MEPs in spinal surgery

PURPOSE

Intraoperative muscle motor evoked potentials (m-MEPs) are widely used in spinal surgery with the aim of identifying a damage to spinal cord at a reversible stage. Generally, lower limb m-MEPs are recorded from abductor hallucis [AH] and the tibialis anterior [TA]. The purpose of this work is to study an unselected population by recording the m-MEPs from TA, AH and extensor digitorum brevis (EDB), with the aim of identifying the most adjustable and stable muscles responses intraoperatively.

METHODS

Transcranially electrically induced m-MEPs were intraoperative recorded in a total of 107 surgical procedures. m-MEPs were recorded by a needle electrode placed in the muscle from TA, AH and EDB muscles in the lower extremities.

RESULTS

Overall monitorability (i.e., at least 1 Lower Limb m-MEP recordable) was 100/107 (93.5%). In the remaining 100 surgeries in 3 cases, the only muscle that could be recorded at baseline was one AH, and in other 2 the EDB. Persistence (i.e., the recordability of m-MEP from baseline to the end of surgery) was 88.7% for TA, 89.8% for AH and 93.8% for EDB.

CONCLUSION

In our series, EDB m-MEPs have demonstrated a recordability superior to TA and a stability similar to AH. The explanations may be different and range from changes in the excitability of the cortical motor neuron to the different sensitivity to ischemia of the spinal motor neuron. EDB can be used alternatively or can be added to TA and AH as a target muscle of the lower limb in spinal surgery.

Indications and possible limitations using medio-plantar plate systems in tarsometatarsal 1 fusions - A cadaveric study

BACKGROUND

The tarsometatarsal 1 arthrodesis is an adequate treatment for moderate to severe hallux valgus deformity and instability of the first ray. Plantar plating arthrodesis has been shown to provide better mechanical stability and fewer postoperative complications than screw fixation or medial plating. The medio-plantar plate is a new plate design for Lapidus arthrodesis. It could combine the biomechanical advantages of the plantar plate and the anatomical overview of a medial plate. However, the implanted material can cause irritation of the tibialis anterior, which in some cases may require removal of the material. The purpose of this study was to examine the possibility of tendon irritation following medio-plantar first tarsometatarsal joint arthrodesis using cadaveric specimens.

METHODS

The study involved the simulated surgical procedure of medio-plantar plate arthrodesis on 30 lower extremities. After the plates were fixed, a thorough examination of the feet was conducted to assess any tendon irritation and to determine a recommendation for placement of the medio-plantar plate based on the Olewnik classification.

RESULTS

Irritation of the tibialis anterior tendon components with the medio-plantar plate depends mainly on the anatomic norm variant, classified according to Olewnik et al. A medio-plantar plate is particularly recommended in TA tendon Olewnik type 3 and type 5. The positioning of a medio-plantar plate in Olewnik type 1 and type 2 tendons depends on the anatomic fit of the medio-plantar plate and the bony configuration of the TMT 1 joint. A large portion of the TA tendon must be detached, so a different plate design may be preferred in these patients.

CONCLUSIONS

TMT 1 arthrodesis with medio-plantar plating of the first tarsometatarsal joint should be performed considering the anatomic TA tendon variations.

LEVEL OF EVIDENCE

Level V, Expert Opinion includes Case Reports and Technique Tips.

Factors associated with improvement in tibialis anterior weakness due to lumbar degenerative disease

BACKGROUND

The weakness of the tibialis anterior remains to be a controversial topic. There has been no study that used electrophysiological assessment of the function of the lumbar and sacral peripheral motor nerves. The aim is to evaluate surgical outcomes in patients with weakness of the tibialis anterior using neurological and electrophysiological assessments.

METHODS

We enrolled 53 patients. Tibialis anterior weakness was quantified by muscle strength, as assessed using a manual muscle test on a scale of 1 through 5, with scores <5 indicating weakness. Postoperative improvement in muscle strength was classified as excellent (5 grades recovered), good (more than one grade recovered), or fair (less than one grade recovered).

RESULTS

Surgical outcomes for tibialis anterior function were categorized as "excellent" in 31, "good" in 8, "fair" in 14 patients. Significant difference in outcomes were observed depending on diabetes mellitus status, type of surgery, and the compound muscle action potentials amplitudes of the abductor hallucis and extensor digitorum brevis (p < 0.05). Surgical outcomes were classified into two groups, patients with excellent and good outcomes (Group 1) and patients with fair outcome (Group 2). Using the forward selection stepwise method, sex and the compound muscle action potentials amplitudes of the extensor digitorum brevis were identified as significant factors for their positive association with Group 1 status. The diagnostic power of the predicted probability was as high as 0.87 in terms of area under curve of the receiver operating characteristic curve.

CONCLUSIONS

There was a significant correlation between the prognosis of tibialis anterior weakness and sex and the compound muscle action potentials amplitude of extensor digitorum brevis, suggesting that recording the compound muscle action potentials amplitude of extensor digitorum brevis will aid the outcome assessment of future surgical interventions for tibialis anterior weakness.

Bridging the muscle genome to phenome across multiple biological scales

Muscle is highly hierarchically organized, with functions shaped by genetically controlled expression of protein ensembles with different isoform profiles at the sarcomere scale. However, it remains unclear how isoform profiles shape whole-muscle performance. We compared two mouse hindlimb muscles, the slow, relatively parallel-fibered soleus and the faster, more pennate-fibered tibialis anterior (TA), across scales: from gene regulation, isoform expression and translation speed, to force-length-velocity-power for intact muscles. Expression of myosin heavy-chain (MHC) isoforms directly corresponded with contraction velocity. The fast-twitch TA with fast MHC isoforms had faster unloaded velocities (actin sliding velocity, Vactin; peak fiber velocity, Vmax) than the slow-twitch soleus. For the soleus, Vactin was biased towards Vactin for purely slow MHC I, despite this muscle's even fast and slow MHC isoform composition. Our multi-scale results clearly identified a consistent and significant dampening in fiber shortening velocities for both muscles, underscoring an indirect correlation between Vactin and fiber Vmax that may be influenced by differences in fiber architecture, along with internal loading due to both passive and active effects. These influences correlate with the increased peak force and power in the slightly more pennate TA, leading to a broader length range of near-optimal force production. Conversely, a greater force-velocity curvature in the near-parallel fibered soleus highlights the fine-tuning by molecular-scale influences including myosin heavy and light chain expression along with whole-muscle characteristics. Our results demonstrate that the individual gene, protein and whole-fiber characteristics do not directly reflect overall muscle performance but that intricate fine-tuning across scales shapes specialized muscle function.

Contribution of sensory feedback to Soleus muscle activity during voluntary contraction in humans

Sensory feedback contributes to plantar flexor muscle activity during walking, but it is unknown whether this is also the case during non-locomotor movements. Here, we explored the effect of reduction of sensory feedback to ankle plantar flexors during voluntary isometric contractions. 13 adult volunteers were seated with the right leg attached to a foot plate which could be moved in dorsi- or plantarflexion direction by a computer-controlled motor. During static plantar flexion while the plantar flexors were slowly stretched, a sudden plantar flexion caused a decline in Soleus EMG at stretch reflex latency. This decline in EMG remained when transmission from dorsiflexors was blocked. It disappeared following block of transmission from plantar flexors. Imposed plantarflexion failed to produce a similar decline in EMG during static or ramp-and-hold plantar flexion in the absence of slow stretch. Instead, a decline in EMG was observed 15-20 ms later, which disappeared following block of transmission from dorsiflexors. Imposed plantarflexion in the stance phase during walking caused a decline in SOL EMG which in contrast remained following block of transmission from dorsiflexors. These findings imply that the contribution of spinal interneurons to the neural drive to muscles during gait and voluntary movement differs and supports that a locomotion specific spinal network contributes to plantar flexor muscle activity during human walking.

Blood flow restriction exercise of the tibialis anterior in people with stroke: a preliminary study

BACKGROUND

Blood flow restriction exercise (BFR-E) could be a useful training adjunct for patients with weakness after stroke to augment the effects of exercise on muscle activity. We aimed to examine neurophysiological changes (primary aim) and assess patient perceptions (secondary aim) following BFR-E.

METHODS

Fourteen participants with stroke performed BFR-E (1 session) and exercise without blood flow restrictsion (Exercise only) (1 session), on two days, ≈7 days apart. In each session, two sets of tibialis anterior (TA) contractions were performed and electromyography (EMG) was recorded. Eight participants underwent transcranial magnetic stimulation (single-pulse stimulation, short interval intracortical inhibition (SICI), intracortical facilitation (ICF)) and peripheral electrical stimulation (maximal peak-to-peak M-wave (M-max)) of the TA before, immediately-after, 10-min-after and 20-min-after BFR-E and Exercise only. Numerical rating scores (NRS) for pain, discomfort, fatigue, safety, focus and difficulty were collected for all subjects (n = 14). Paired comparisons and linear mixed models assessed the effects of BFR-E and Exercise only.

RESULTS

No adverse events due to exercise were reported. There was no contraction-number × condition interaction for EMG amplitude during exercise (p = 0.15), or time × condition interaction for single-pulse stmulation, SICI, ICF or M-max amplitude (p = 0.34 to p = 0.97). There was no difference between BFR-E and Exercise only in NRS scores (p = 0.10 to p = 0.50).

CONCLUSION

Using our training paradigm, neurophysiological parameters, feasibility, tolerability and perceptions of safety were not different between BFR-E and Exercise only. As participants were generally well-functioning, our results are not generalizable to lower functioning people with stroke, different (more intense) exercise protocols or longer term training over weeks or months.

Treatment of spastic varus/ equinovarus foot with split-tendon transfers in cerebral palsy: How does it affect the hindfoot motion?

INTRODUCTION

The flexible spastic varus foot in cerebral palsy is commonly corrected by split-tendon transfer of tibialis anterior or tibialis posterior. These tendon transfers are said to preserve hindfoot motion, which is until now not been proven. Therefore, the aim of the study was to show the hindfoot motion following split-tendon transfer in comparison to a midtarsal arthrodesis.

MATERIALS AND METHODS

A retrospective study was done on patients with flexible spastic varus foot in cerebral palsy who underwent a combined split-tendon transfer of tibialis anterior and posterior. Patients with a rigid foot deformity underwent a midfoot arthrodesis. These children and normal children served as controls. An instrumented gait analysis was done in all patients before and at follow-up. A statistical analysis was done using 2-factor ANOVA with repeated measures on time.

RESULTS

Thirteen children underwent a combined split-tendon transfers of tibialis anterior and posterior muscles and 14 children midtarsal arthrodesis. The mean follow-up was 2.4 (SD=0.8) years for flexible varus foot and 1.9 (SD=0.7) years for rigid foot deformity. The preoperative hindfoot range of motion in eversion-inversion was 54% and 49% of TD controls in flexible varus foot and rigid foot deformity respectively. At follow-up, it reduced further to 45% and 42% of TD controls in the respective groups.

CONCLUSION

Both flexible and rigid hindfoot deformity reduced the hindfoot motion. However following surgery, the hindfoot motion reduced further and was identical in both groups independent of the type of surgery. This indicates a tenodesis-effect of split-tendon transfers on the hindfoot.

Clinical results of distal anterior tibial tendon decompression

BACKGROUND

Distal tibialis anterior tendinopathy (DTAT) is condition which is infrequently described in literature and is usually treated with conservative means. If resistant to a rehabilitation protocol and unloading, a surgical treatment could be proposed. The aim of this research is to report on the history and clinical image of DTAT and present the clinical results of a simple surgical decompression of the tendon with local debridement and release of the distal extensor retinaculum.

METHODS

Seventeen patients diagnosed with DTAT in 18 feet underwent surgery between 2008 and 2018. Upon initial presentation, all patients reported a persistent history of pain over the tibialis anterior (TA) insertion. Ultrasound was routinely performed to confirm the diagnosis. In patients with confirmed diagnosis of DTAT, persistent despite conservative treatment, we proceeded with surgical intervention during which we released the tendon by opening the distal extensor retinaculum. Retrospective chart review was performed, and functional outcomes were assessed using the AOFAS midfoot score. AOFAS score results were collected postoperatively with at least one-year follow-up.

RESULTS

All patients experienced pain on palpation of the distal aspect of the TA tendon. Most patients experienced pain at night and were frequent hikers. Our study population consisted of mostly female and overweight patients. All patients reported pain relief with a significant improvement of VAS for pain from 6.7 ± 1.1 preoperatively to 1.1 ± 1.2 postoperatively (p < 0.05). The postoperative AOFAS midfoot score was 97 ± 3.7. Fifteen patients were completely satisfied, two satisfied with minor reservations.

CONCLUSION

Simple distal TA tendon release by division of a consistently present constricting distal extensor retinaculum represents a surgical alternative in the treatment of chronic DTAT. Our study shows good clinical outcomes with low complications.

LEVEL OF EVIDENCE

Level IV - retrospective case series.

Comparing cortico-motor hotspot identification methods in the lower extremities post-stroke: MEP amplitude vs. latency

Transcranial magnetic stimulation (TMS) is a technique used to probe and measure cortico-motor responses of the nervous system. However, lower extremity (LE) specific methodology has been slow to develop. In this retrospective analysis, we investigated what motor evoked potential metric, amplitude (MEP_amp) or latency (MEP_lat), best distinguished the motor-cortical target, i.e. hotspot, of the tibialis anterior and soleus post-stroke. Twenty-three participants with stroke were included in this investigation. Neuronavigation was used to map hotspots, derived via MEP_amp and MEP_lat, over a 3cm × 5cm grid. Distances between points with the greatest response within a session and between days were compared. Both criterion, amplitude and latency, provided poor identification of locations between trials within a session, and between multiple visits. Identified hotspots were similar only 15 % and 8% of the time between two assessments within the same session, for amplitude and latency respectively. However, MEP_amp was more consistent in identifying hotspots, evidenced by locations being less spatially distant from each other (Amplitude: 1.4 cm (SD 0.10) Latency: 1.7 (SD 1.04), P = 0.008) within a session and between days (Amplitude: 1.3 cm (SD 0.95), Latency 1.9 cm (SD 1.14), P = 0.004). While more work is needed to develop LE specific methodology for TMS, especially as it applies to investigating gait impairments, MEP_amp appears to be a more consistent criterion for hotspot identification when compared to MEP_lat. It is recommended that future works continue to use MEP_amp when identifying tibialis anterior and soleus hotspots using neuronavigation.

Differential corticomotor mechanisms of ankle motor control in post stroke individuals with and without motor evoked potentials

OBJECTIVE

Deficits in ankle motor control has been identified as a significant contributor to impaired walking after stroke. Corticomotor excitability has been related to impaired upper limb motor control and poor recovery in stroke, however contributions to lower limb function are still unclear. This study used transcranial magnetic stimulation (TMS) to determine the influence of corticomotor characteristics on lower limb motor control in chronic stroke survivors.

METHODS

This retrospective study assessed 28 individuals with post stroke hemiparesis. Motor evoked potentials (MEP) measured from the paretic and non-paretic tibialis anterior (TA) muscles were used to calculate corticomotor excitability symmetry (CME_sym) and relative ipsilateral corticomotor excitability (ICE). Participants were assigned to MEP+ and MEP- groups depending on the presence (+) or absence (-) of MEPs. Ankle motor control was quantified by the ability of participants to track a sinusoidal target using dorsiflexion-plantarflexion movements of the paretic ankle and tracking error was calculated using root mean square error (RMSE).

RESULTS

Multiple linear regression model for all participants revealed only CME_sym and FMLE (p < 0.01) to significantly predict RMSE. In the MEP+ group, CME_sym significantly predicted RMSE (p = 0.03) while FMLE (p = 0.02) was a significant predictor for the MEP-.

CONCLUSION

Our results indicate that CME_sym between the ipsilesional and contralesional hemispheres does not necessarily translate to better paretic ankle motor control in chronic stroke. Presence or absence of a MEP in the TA muscle did not affect the ankle tracking performance, however, it was noted that different strategies maybe used by those with and without a MEP.

Anatomical study of Lapidus arthrodesis using two different plantar plate systems

BACKGROUND

First tarsometatarsal arthrodesis (modified Lapidus procedure) constitutes a sufficient treatment for moderate to severe hallux valgus deformity and first ray instability. The plantar plate arthrodesis was shown to provide superior mechanical stability and less postoperative complications than screw fixation or dorsal plating. Nevertheless, the in-brought hardware may cause irritation of the tibialis anterior or peroneus longus tendon requiring explantation of the material in some cases. The purpose of this study was to investigate the potential of tendon irritation after plantar first tarsometatarsal joint arthrodesis in a cadaver study.

METHODS

Plantar plate arthrodesis was performed as in real surgery on twelve pairs of fresh frozen cadaveric feet. Two different plate systems were randomly allocated to each pair of feet. After plate fixation careful dissection of the feet followed to analyze potential tendon irritation and to determine a "safe zone" for plantar plate placement.

RESULTS

A "safe zone" between the insertion sties of tibialis anterior and peroneus longus tendon was found and proven to be sufficiently exposed using a standard medio-plantar approach. Both plates were fixed in this zone without compromising central tendon parts. Peripheral tendon parts were irritated in 42% using Darco Plantar Lapidus Plating System® (Wright Medical, Memphis, TN) and in 8% using the Plantar Lapidus Plate® (Arthrex, Naples, FL). Bending of the anatomically preshaped plates is often necessary to ensure optimal fit on the bone surface.

CONCLUSIONS

Modified Lapidus procedure with plantar plating of the first tarsometatarsal joint can be performed safely without compromising central tendon parts via standard medio-plantar approach.

LEVEL OF CLINICAL EVIDENCE

5, Cadaver Study.

Intraoperative monitoring of corticospinal tracts in anterior cervical decompression and fusion surgery: Excitability differentials of lower extremity muscles

•

Lower extremity (LE) muscles demonstrate intraoperative excitability differences.

•

Abductor hallucis is a suitable LE muscle for monitoring the corticospinal tract (CST).

•

CST monitoring with two LE muscles includes advantages but also practical limitations.

Objective

This study examines and compares excitability characteristics of tibialis anterior (TA) and abductor hallucis (AH) transcranial motor evoked potentials (tcMEP) during anterior cervical decompression and fusion (ACDF) surgery.

Methods

Electrophysiological and clinical data of 89 patients who underwent ACDF procedure were retrospectively reviewed. TcMEP data of TA and AH muscles from 178 limbs were analyzed for availability, robustness and stability during the procedure.

Results

TA tcMEP was available at 83% whereas AH tcMEP was available at 99% of the monitored lower limbs at preposition baseline. Availability of both TA and AH tcMEP was demonstrated in 147/178 limbs. The baseline amplitude of AH tcMEP was significantly greater than that of TA tcMEP recorded from the same limb (744.6 ± 54.0 and 326.9 ± 33.3 µV, respectively). Simultaneous deterioration of TA and AH tcMEP data was demonstrated in 10/147 limbs. Deterioration of either TA or AH tcMEP data accompanied by unchanged tcMEP data from the other lower limb muscle was noted in 32/147 compared to 1/147 limbs, respectively. The deteriorated TA and AH tcMEP data returned to baseline before closing at incidence of 17% compared to 46%, respectively. No new lower extremity (LE) neurological deficit was presented postoperatively in any patient.

Conclusions

AH tcMEP is a more reliable candidate than TA tcMEP for intraoperative LE monitoring in ACDF procedure.

Significance

The excitability differentials in LE tcMEP in ACDF is a variable that need to be considered while interpreting intraoperative neurophysiological data.

Allograft Reconstruction of Spontaneous Tibialis Anterior Tendon Rupture in a Diabetic Patient

Introduction:

The tibialis anterior (TA) is a powerful dorsiflexor of the ankle. Ruptures of the TA can be a distressing condition that needed a surgical intervention. Fortunately, despite being the third most common lower limb tendon rupture (after Achilles and patellar tendon), ruptures of the TA remain a rare clinical entity. We present a case of spontaneous rupture of the TA in an elderly diabetic lady as well as our successful repair using a TA allograft to bridge the defect gap.

Case Report:

A 73-year-old known diabetic lady complains of a 6-month history of progressive right ankle pain and swelling over the dorsum of her foot. She did not recall any trauma or twisting injury. She had tenderness over the anterior ankle, an erythematous cystic soft tissue mass, and weakness in ankle dorsiflexion. In addition, she demonstrated notable prominent first metatarsophalangeal hyperextension on ankle dorsiflexion. Loss of contour of normal TA anatomy was noted over anterior aspect of ankle joint. Magnetic resonance imaging reported a complete rupture of the TA tendon with a 4.2 cm tendon gap. Surgical repair using a TA allograft whip stitched side to side to the proximal TA stump and the remaining allograft secured on the medial cuneiform with bio absorbable screw. Rehabilitation consisted of a structured program with protected weight bearing. At 3 months after surgical repair, the patient was able to return to daily activities.

Conclusion:

This case report highlights the successful use of a TA allograft in the repair of a chronic TA rupture in an elderly diabetic patient. This repair has demonstrated to be reliable at 12-month post-surgery and allows prompt return to daily activities.

Morphological variations and accessory ossicles in the peroneal and tibialis muscles

This study describes five bilateral anatomical variations in the feet of a 97-year-old male cadaver. Following routine dissection, all variants were measured and documented. Three accessory tendons and two accessory ossicles were identified. Bilateral accessory tendons were present from the tibialis anterior (type II), peroneus tertius (type III), and peroneus brevis muscles. Accessory tendon length was 36–104 mm and width was 1–3 mm each inserting more distally then the main tendon. Accessory ossicles were identified as an accessory navicular and os peroneum, respectively. Individually, each variation has varying prevalence rates in the literature, but to date, no known studies have been published describing the combined presence of all five bilateral variations. The acknowledgement of multi-variant cases such as this one may be helpful in the clinical setting, particularly for patients with pathology or for those undergoing foot and ankle surgery.

Tibialis anterior tendinosis: Clinical characterization and surgical treatment

BACKGROUND

Tibialis anterior (TA) tendinosis is rarely reported on in the literature. It is seen in patients older than 45 and causes weakness in dorsiflexion. This paper aims to describe surgical treatment and clinical outcomes.

METHODS

Between 2015 and 2018, nine patients (six females, three males) with severe TA tendinosis with no tear (2), partial (1), or complete (6) underwent operative treatment. Patients underwent debridement and direct repair without augmentation, direct repair with fiber tape augmentation, tibialis posterior tendon (PTT) transfer, or tibialis anterior tendon (TAT) augmentation with a tendon autograft (n=4). Autografts consisted of extensor digitalis longus (EDL) tendon, plantaris tendon, or both.

RESULTS

Mean postoperative follow-up was 21.3 (range 8-31) months. All patients had a concomitant gastrocnemius recession, and three had hindfoot arthrodesis. Preoperative dorsiflexion strength was 0/5 for all and improved to 5/5 postoperatively in seven. The only current smoker developed wound dehiscence 2 weeks postoperatively and healed by 4. One developed marginal skin necrosis 3 weeks postoperatively and was treated successfully with casting.

CONCLUSION

Surgery reestablished function in individuals with TA tendinosis and allowed high level of satisfaction. Direct repair is possible. If the tendon gap is too large an autograft of EDL and plantaris tendon can be utilized.

LEVEL OF EVIDENCE

Level III Retrospective Comparative Study.

Medium latency excitatory reflex of soleus re-examined

We aimed to study the receptor origin and postsynaptic potential profile of the medium latency reflex (MLR) response that develops in the soleus muscle when common peroneal nerve of antagonist tibialis anterior (TA) muscle is electrically stimulated. To achieve this aim, we electrically stimulated common peroneal nerve and recorded surface electromyography (SEMG) responses of soleus and TA muscles of informed volunteers. Additionally, we recorded intramuscular EMG from the soleus muscle. Stimulation of common peroneal nerve induced a direct motor response (M-response) in the TA and MLR in SEMG of the soleus. Using voluntarily-activated single motor units (SMUs) from the soleus muscle we noted that there were two distinct responses following the stimulus. The first response was a reciprocal inhibitory reflex probably originating from the antagonist muscle spindle primary (Ia) afferents. This was followed by an indirect reflex response activated by the contraction of the TA muscle during the M-response. This contraction generated a rapid acceleration in the direction of dorsiflexion hence inducing a stretch stimulus on soleus muscle. The response of soleus to this stimulus was a stretch reflex. We suggest that this stretch reflex is the main contributor to the so-called soleus MLR in the literature. This study illustrated the importance of using SMUs and also using discharge-rate based analysis for closely examining previously 'established' reflexes.

Tibialis anterior tendon traumatic rupture secondary to a closed talar neck fracture: A case report

A case of a 22 year-old woman who sustained a closed Hawkins type II talar neck fracture after her left foot was caught in a rope while rock climbing outdoors is described. She presented to emergency department with a swollen and neurovascularly intact foot and a displaced talar neck fracture was identified. Intraoperatively a traumatic rupture of tibialis anterior tendon was found and was primarily repaired after the talar fixation. Revisiting the mechanism of injury it was evident that the jagged fracture ends ruptured the tibialis anterior tendon while she was hanging upside down on the strapping with the foot in forced equinus. This is the first case of such complication associated with a talar fracture and signifies the importance of tibialis anterior examination in such fractures.

Changes in the ankle muscles co-activation pattern after 5 years following total ankle joint replacement

BACKGROUND

The Hintegra® arthroplasty provides inversion-eversion stability, permits axial rotation, ankle flexion-extension, and improvements of the gait patterns are expected up to 12 months of rehabilitation. However, sensorimotor impairments are observed in ankle flexors/extensors muscles after rehabilitation, with potential negative effects on locomotion. Here we determined the timing and amplitude of co-activation of the tibialis anterior and medial gastrocnemius muscles during gait by assessing non-operated and operated legs of patients with total ankle replacement, 5 years after surgery.

METHODS

Twenty-nine patients (age: 58 [5.5] years, height: 156.4 [6.5] cm, body mass: 72.9 [6.5] kg, 10 men, and 19 women) that underwent Hintegra® ankle arthroplasty were included. Inclusion criteria included 5 years prosthesis survivorship. The onset and offset of muscle activation (timing), as well as the amplitude of activation, were determined during barefoot walking at self-selected speed by surface electromyography. The timing, percentage, and index of co-activation between the tibialis anterior and medial gastrocnemius were quantified and compared between non-operated and operated legs.

FINDINGS

The operated leg showed higher co-activation index and temporal overlapping between tibialis anterior and medial gastrocnemius during gait (p < 0.001).

INTERPRETATION

The neuromuscular changes developed during the process of degeneration do not appear to be restored 5 years following arthroplasty. The insertion of an ankle implant may restore anatomy and alignment but neuromuscular adaptations to degeneration are not corrected by 5 years following joint replacement.

The influence of residual force enhancement on spinal and supraspinal excitability

Background

Following active muscle lengthening, there is an increase in steady-state isometric force as compared with a purely isometric contraction at the same muscle length and level of activation. This fundamental property of skeletal muscle is known as residual force enhancement (RFE). While the basic mechanisms contributing to this increase in steady-state isometric force have been well documented, changes in central nervous system (CNS) excitability for submaximal contractions during RFE are unclear. The purpose of this study was to investigate spinal and supraspinal excitability in the RFE isometric steady-state following active lengthening of the ankle dorsiflexor muscles.

Methods

A total of 11 male participants (20–28 years) performed dorsiflexions at a constant level of electromyographic activity (40% of maximum). Half of the contractions were purely isometric (8 s at an ankle angle of 130°), and the other half were during the RFE isometric steady-state following active lengthening (2 s isometric at 90°, a 1 s lengthening phase at 40°/s, and 5 s at 130°). Motor evoked potentials (MEPs), cervicomedullary motor evoked potentials (CMEPs), and compound muscle action potentials (M-waves) were recorded from the tibialis anterior during the purely isometric contraction and RFE isometric steady-state.

Results

Compared to the purely isometric condition, following active lengthening, there was 10% RFE (p < 0.05), with a 17% decrease in normalized CMEP amplitude (CMEP/M_max) (p < 0.05) and no change in normalized MEP amplitude (MEP/CMEP) (p > 0.05).

Discussion

These results indicate that spinal excitability is reduced during submaximal voluntary contractions in the RFE state with no change in supraspinal excitability. These findings may have further implications to everyday life offering insight into how the CNS optimizes control of skeletal muscle following submaximal active muscle lengthening.

Injection-Based Delivery of Cell-Permeable Peptide-Tagged Cre

The technique of Cre-mediated DNA recombination at loxP sites has been used widely in manipulation of the genome in cultured cells and in living organisms. Local delivery of Cre recombinase protein tagged with a cell-penetrating (or permeable) peptide (Cre-CPP) has the advantage of additional spatial and temporal control when compared to genetic delivery methods. In this chapter, we describe protocols for injection-based intramuscular delivery of Cre-CPP dissolved in hydrogel to skeletal muscle and by ultrasound-guided injection to cardiac muscle in mice.

Characterizing the corticomotor connectivity of the bilateral ankle muscles during rest and isometric contraction in healthy adults

The investigation of the corticomotor connectivity (CMC) to leg muscles is an emerging research area, and establishing reliability of measures is critical. This study examined the measurement reliability and the differences between bilateral soleus (SOL) and tibialis anterior (TA) CMC in 21 neurologically intact adults. Using single pulse transcranial magnetic stimulation (TMS), each muscle's CMC was assessed twice (7 ± 2 days apart) during rest and active conditions. CMC was quantified using a standardized battery of eight measures (4/condition): motor threshold during resting (RMT), motor evoked potential amplitude and latency (raw and normalized to height) in both conditions, contralateral silent period (CSP) during active. Using two reliability metrics (intraclass correlation coefficient and coefficient of variation of method error; good reliability: ≥0.75 and ≤15, respectively) and repeated-measures ANOVA, we investigated the reliability and Muscle X Body Side interaction. For both muscles, RMT, resting raw and normalized latencies, and active raw latency demonstrated good reliability, while CSP had good reliability only for TA. Amplitude did not demonstrate good reliability for both muscles. SOL CMC was significantly different from TA CMC for all measures but CSP; body side had no significant effect. Therefore, only certain measures may reliably quantify SOL and TA CMC while different CMC (except CSP) between SOL and TA suggests dissimilar corticospinal drive to each muscle regardless of the side.

Calcific myonecrosis: diagnostic dilemma

Calcific myonecrosis is a rare benign condition affecting mainly the muscles of a single leg compartment. It is thought to follow a history of trauma with a latent period of years. Patients present with a slowly growing mass. Differential diagnosis from a malignant tumour can be made from the history and the distinctive radiographical features of a fusiform lesion with predominantly peripheral calcifications. Magnetic resonance imaging may be necessary to confirm the diagnosis; treatment is largely symptomatic.

Hamstring autograft maturation is superior to tibialis allograft following anatomic single-bundle anterior cruciate ligament reconstruction

PURPOSE

Using second-look arthroscopy, graft maturation was investigated and compared between hamstring (HA) autografts and tibialis anterior (TA) allografts after anatomic single-bundle anterior cruciate ligament reconstruction (ACLR).

METHODS

Fifty-six patients who underwent second-look arthroscopy after anatomic single-bundle ACLR with either HA autografts (26, HA group) or TA allografts (30, TA group) from 2007 to 2016 were retrospectively reviewed. Graft maturation on second-look arthroscopy was evaluated in terms of four parameters: graft integrity (tear), synovial coverage, graft tension, and graft vascularization. Each parameter received a maximum of two points, depending on the status of the reconstructed graft. The total graft maturation score was calculated as the sum of the parameter scores. The total graft maturation and individual parameter scores were compared between the two groups.

RESULTS

The mean time from ACLR to second-look arthroscopy was 22.5 ± 7.8 months. The maturation scores in the HA group were significantly better in terms of graft integrity (p = 0.041), graft tension (p = 0.010), and graft vascularization (p = 0.024), whereas the graft synovial coverage score was not significantly different. The total graft maturation score of the HA group was significantly higher than that of the TA group (6.3 ± 0.4 vs. 4.9 ± 0.3, p = 0.013).

CONCLUSIONS

This study shows the superior graft maturation of HA autografts compared with that of TA allografts at a mean follow-up of 22.5 ± 7.8 months after anatomic single-bundle ACLR. When anatomic ACLR using soft tissue graft is planned, HA autograft is recommended rather than soft tissue allograft, especially in young and active patients.

LEVEL OF EVIDENCE

Retrospective cohort review, Level III.

High-frequency electrical stimulation (HFES) data lean and obese Zucker rat tibialis anterior muscle: Regulation of glycogen synthase kinase 3 beta (GSK3B) associated proteins

Anaerobic exercise has been advocated as a prescribed treatment for the management of diabetes: however, alterations in exercise-induced signaling remain largely unexplored in the diabetic muscle. Here, we compare the basal and the in situ contraction-induced phosphorylation of the AMPK, GSK3beta, and Shp2 in the lean and obese (fa/fa) Zucker rat tibialis anterior (TA) muscle following a single bout of contractile stimuli. This article represents data associated with prior publications from our lab (Katta et al., 2009; Katta et al., 2009; Tullgren et al., 1991) [1–3] and concurrent Data in Brief articles (Ginjupalli et al., 2017; Rice et al., 2017; Rice et al., 2017; Rice et al., 2017) [4–7].

Changes in tibialis anterior architecture affect the amplitude of surface electromyograms

Background

Variations in the amplitude of surface electromyograms (EMGs) are typically considered to advance inferences on the timing and degree of muscle activation in different circumstances. Surface EMGs are however affected by factors other than the muscle neural drive. In this study, we use electrical stimulation to investigate whether architectural changes in tibialis anterior (TA), a key muscle for balance and gait, affect the amplitude of surface EMGs.

Methods

Current pulses (500 μs; 2 pps) were applied to the fibular nerve of ten participants, with the ankle at neutral, full dorsi and full plantar flexion positions. Ultrasound images were collected to quantify changes in TA architecture with changes in foot position. The peak-to-peak amplitude of differential M waves, detected with a grid of surface electrodes (16 × 4 electrodes; 10 mm inter-electrode distance), was considered to assess the effect of changes in TA architecture on the surface recordings.

Results

On average, both TA pennation angle and width increased by respectively 7 deg. and 9 mm when the foot moved from plantar to dorsiflexion (P < 0.02). M-wave amplitudes changed significantly with ankle position. M waves elicited in dorsiflexion and neutral positions were ~25% greater than those obtained during plantar flexion, regardless of where they were detected in the grid (P < 0.001). This figure increased to ~50% when considering bipolar M waves.

Conclusions

Findings reported here indicate the changes in EMG amplitude observed during dynamic contractions, especially when changes in TA architecture are expected (e.g., during gait), may not be exclusively conceived as variations in TA activation.

Muscular activity and torque of the foot dorsiflexor muscles during decremental isometric test: A cross-sectional study

PURPOSE

To analyse the torque variation level that could be explained by the muscle activation (EMG) amplitude of the three major foot dorsiflexor muscles (tibialis anterior (TA), extensor digitorum longus (EDL), extensor hallucis longus (EHL)) during isometric foot dorsiflexion at different intensities.

METHODS

In a cross-sectional study, forty-one subjects performed foot dorsiflexion at 100%, 75%, 50% and 25% of maximal voluntary contractions (MVC) with the hip and knee flexed 90° and the ankle in neutral position (90° between leg and foot). Three foot dorsiflexions were performed for each intensity. Outcome variables were: maximum (100% MVC) and relative torque (75%, 50%, 25% MVC), maximum and relative EMG amplitude. A linear regression analysis was calculated for each intensity of the isometric foot dorsiflexion.

RESULTS

The degree of torque variation (dependent variable) from the independent variables explain (EMG amplitude of the three major foot dorsiflexor muscles) the increases when the foot dorsiflexion intensity is increased, with values of R² that range from 0.194 (during 25% MVC) to 0.753 (during 100% MVC). The reliability of the outcome variables was excellent.

CONCLUSION

The EMG amplitude of the three main foot dorsiflexors exhibited more variance in the dependent variable (torque) when foot dorsiflexion intensity increases.

Can kinesio tape be used as an ankle training method in the rehabilitation of the stroke patients?

OBJECTIVE

To investigate the effects of the kinesio tape application to the tibialis anterior on rehabilitation outcomes of the stroke patients.

DESIGN AND SETTING

Twenty patients with stroke were allocated into two groups: the first group of ten patients was assigned to receive kinesio tape in addition to the conventional rehabilitation program while a second group of 10 patients was assigned to receive a conventional rehabilitation program only.

MAIN OUTCOME MEASURES

The clinical variables and health-related quality of life (HRQoL) were evaluated at baseline and at the end of the forth week.

RESULTS

The present study showed that kinesio tape application to the tibialis anterior has significant effects on motor recovery of the lower extremity, spasticity, ambulation capacity, HRQoL and gait compared to the control group and baseline.

CONCLUSIONS

The results of this study suggest that kinesio tape can be used as an ankle training method.

Inhibition of Stat3 signaling ameliorates atrophy of the soleus muscles in mice lacking the vitamin D receptor

Background

Although skeletal muscle wasting has long been observed as a clinical outcome of impaired vitamin D signaling, precise molecular mechanisms that mediate the loss of muscle mass in the absence of vitamin D signaling are less clear. To determine the molecular consequences of vitamin D signaling, we analyzed the role of signal transducer and activator of transcription 3 (Stat3) signaling, a known contributor to various muscle wasting pathologies, in skeletal muscles.

Methods

We isolated soleus (slow) and tibialis anterior (fast) muscles from mice lacking the vitamin D receptor (VDR^−/−) and used western blot analysis, quantitative RTPCR, and pharmacological intervention to analyze muscle atrophy in VDR^−/− mice.

Results

We found that slow and fast subsets of muscles of the VDR^−/− mice displayed elevated levels of phosphorylated Stat3 accompanied by an increase in Myostatin expression and signaling. Consequently, we observed reduced activity of mammalian target of rapamycin (mTOR) signaling components, ribosomal S6 kinase (p70S6K) and ribosomal S6 protein (rpS6), that regulate protein synthesis and cell size, respectively. Concomitantly, we observed an increase in atrophy regulators and a block in autophagic gene expression. An examination of the upstream regulation of Stat3 levels in VDR^−/− muscles revealed an increase in IL-6 protein expression in the soleus, but not in the tibialis anterior muscles. To investigate the involvement of satellite cells (SCs) in atrophy in VDR^−/− mice, we found that there was no significant deficit in SC numbers in VDR^−/− muscles compared to the wild type. Unlike its expression within VDR^−/− fibers, Myostatin levels in VDR^−/− SCs from bulk muscles were similar to those of wild type. However, VDR^−/− SCs induced to differentiate in culture displayed increased p-Stat3 signaling and Myostatin expression. Finally, VDR^−/− mice injected with a Stat3 inhibitor displayed reduced Myostatin expression and function and restored active p70S6K and rpS6 levels, resulting in an amelioration of loss of muscle mass in the soleus muscles.

Conclusions

The loss of muscle mass in slow muscles in the absence of vitamin D signaling is due to elevated levels of phosphorylated Stat3 that leads to an increase in Myostatin signaling, which in turn decreases protein synthesis and fiber size through the phosphorylation of p70S6K and rpS6, respectively.

Electronic supplementary material

The online version of this article (doi:10.1186/s13395-017-0121-2) contains supplementary material, which is available to authorized users.

A prospective randomized comparison of two distinct allogenic tissue constructs for anterior cruciate ligament reconstruction

BACKGROUND

Conduct a prospective randomized study to compare clinical outcomes of anterior cruciate ligament (ACL) reconstruction using quadrupled hamstring tendon (HT) allograft or doubled tibialis anterior (TA) allograft. Limited level 1 data exist comparing outcomes of different soft tissue allograft constructs for ACL reconstruction. We hypothesized no difference would exist in the patient reported outcomes (PRO), arthrometric testing, or rate of re-rupture between the two constructs.

METHODS

Ninety eight subjects undergoing primary ACL reconstruction were randomized to HT (n=47) or TA (n=51) allograft. Subjects completed validated (PRO) measures pre-operatively, and six months and two years post-operatively. Arthrometric testing was performed at six months to assess integrity of the reconstruction.

RESULTS

Fifty-eight percent of subjects (57/98) completed a two-year follow up. Allograft re-tear rates were similar between groups (6.2% HT vs. 4.0% TA, respectively, p=1.0). The relative risk of re-tear in the HT group was 1.5 compared to the TA group (p=0.7). The TA group improved significantly more on the physical portion of the VR-12 (p=0.046) and Lysholm score (p=0.014) compared to the HT group. There was no difference in the change from baseline for the other PRO scores at two years.

CONCLUSIONS

Our data indicate no difference in graft failure rate and similar improvement from baseline in most PRO scores between treatment groups after two years. Based on these findings, TA allograft appears to provide a reliable and satisfactory option for patients who elect to undergo allograft ACL reconstruction.

Characterization of three dimensional volumetric strain distribution during passive tension of the human tibialis anterior using Cine Phase Contrast MRI

Intramuscular pressure correlates strongly with muscle tension and is a promising tool for quantifying individual muscle force. However, clinical application is impeded by measurement variability that is not fully understood. Previous studies point to regional differences in IMP, specifically increasing pressure with muscle depth. Based on conservation of mass, intramuscular pressure and volumetric strain distributions may be inversely related. Therefore, we hypothesized volumetric strain would decrease with muscle depth. To test this we quantified 3D volumetric strain in the tibialis anterior of 12 healthy subjects using Cine Phase Contrast Magnetic Resonance Imaging. Cine Phase Contrast data were collected while a custom apparatus rotated the subjects' ankle continuously between neutral and plantarflexion. A T2-weighted image stack was used to define the resting tibials anterior position. Custom and commercial post-processing software were used to quantify the volumetric strain distribution. To characterize regional strain changes, the muscle was divided into superior-inferior sections and either medial-lateral or anterior-posterior slices. Mean volumetric strain was compared across the sections and slices. As hypothesized, volumetric strain demonstrated regional differences with a decreasing trend from the anterior (superficial) to the posterior (deep) muscle regions. Statistical tests showed significant main effects and interactions of superior-inferior and anterior-posterior position as well as superior-inferior and medial-lateral position on regional strain. These data support our hypothesis and imply a potential relationship between regional volumetric strain and intramuscular pressure. This finding may advance our understanding of intramuscular pressure variability sources and lead to more reliable measurement solutions in the future.

Design Considerations of a Fiber Optic Pressure Sensor Protective Housing for Intramuscular Pressure Measurements

Intramuscular pressure (IMP), defined as skeletal muscle interstitial fluid pressure, reflects changes in individual muscle tension and may provide crucial insight into musculoskeletal biomechanics and pathologies. IMP may be measured using fiber-optic fluid pressure sensors, provided the sensor is adequately anchored to and shielded from surrounding muscle tissue. Ineffective anchoring enables sensor motion and inadequate shielding facilitates direct sensor-tissue interaction, which result in measurement artifacts and force-IMP dissociation. The purpose of this study was to compare the effectiveness of polyimide and nitinol protective housing designs to anchor pressure sensors to muscle tissue, prevent IMP measurement artifacts, and optimize the force-IMP correlation. Anchoring capacity was quantified as force required to dislodge sensors from muscle tissue. Force-IMP correlations and non-physiological measurement artifacts were quantified during isometric muscle activations of the rabbit tibialis anterior. Housing structural integrity was assessed after both anchoring and activation testing. Although there was no statistically significant difference in anchoring capacity, nitinol housings demonstrated greater structural integrity and superior force-IMP correlations. Further design improvements are needed to prevent tissue accumulation in the housing recess associated with artificially high IMP measurements. These findings emphasize fundamental protective housing design elements crucial for achieving reliable IMP measurements.

Recovery from volumetric muscle loss injury: A comparison between young and aged rats

Termed volumetric muscle loss (VML), the bulk loss of skeletal muscle tissue either through trauma or surgery overwhelms the capacity for repair, leading to the formation of non-contractile scar tissue. The myogenic potential, along with other factors that influence wound repair are known to decline with age. In order to develop effective treatment strategies for VML injuries that are effective across a broad range of patient populations, it is necessary to understand how the response to VML injury is affected by aging. Towards this end, this study was conducted to compare the response of young and aged animal groups to a lower extremity VML injury. Young (3months, n=12) and aged (18months, n=8) male Fischer 344 rats underwent surgical VML injury of the tibialis anterior muscle. Three months after VML injury it was found that young TA muscle was on average 16% heavier than aged muscle when no VML injury was performed and 25% heavier when comparing VML treated young and aged animals (p<0.0001, p<0.0001). Peak contractile force for both the young and aged groups was found to decrease significantly following VML injury, producing 65% and 59% of the contralateral limbs' peak force, respectively (p<0.0001). However, there were no differences found for peak contractile force based on age, suggesting that VML affects muscle's ability to repair, regardless of age. In this study, we used the ratio of collagen I to MyoD expression as a metric for fibrosis vs. myogenesis. Decreasing fiber cross-sectional area with advancing age (p<0.005) coupled with the ratio of collagen I to MyoD expression, which increased with age, supports the thought that regeneration is impaired in the aged population in favor of fibrosis (p=0.0241). This impairment is also exacerbated by the contribution of VML injury, where a 77-fold increase in the ratio of collagen I to MyoD was observed in the aged group (p<0.0002). The aged animal model described in this study provides a tool for investigators exploring not only the development of VML injury strategies but also the effect of aging on muscle regeneration.

Limited mechanical effects of intermuscular myofascial connections within the intact rat anterior crural compartment

Skeletal muscles of the rat anterior crural compartment are mechanically connected by epimuscular myofascial connections, but the relevance for mechanical muscle function within physiological ranges of joint motion is unclear. We evaluated the net effect at the ankle joint of epimuscular myofascial connections between tibialis anterior (TA) and extensor digitorum longus (EDL) muscles in the rat (n=8) and determined which anatomical structures may mediate such epimuscular mechanical interactions. We assessed (1) effects of knee angle (i.e. changes in EDL length and position relative to TA) and interactions of knee angle with fasciotomy and proximal EDL tenotomy on TA ankle moment and (2) the effect of knee angle on TA and EDL ankle moment summation. Knee angle was varied between 60° and 130°. Ankle angle was kept constant (90°). TA and EDL were excited individually and simultaneously (TA&EDL). The mathematical sum of individual TA and EDL moments was compared with the moment exerted by TA&EDL to assess the extent of non-additive ankle moment summation. Magnitude of TA ankle moment was not affected by knee angle, but frontal plane moment direction was. However, dissections indicated that this was not caused by the compartmental fascia or EDL length changes. Moment summation was non-additive in magnitude (+1.1±1.1% mean±s.d.) and frontal plane direction. The latter was affected by knee angle and ranged from +0.2±0.3° at 60° to +1.1±0.6° at 130°. As the net effects found were very limited, we conclude that myofascial connections between muscles in the anterior crural compartment have limited mechanical relevance during normal movement.

Foot Dorsiflexion Velocity and Torque Variance Explained through Architectural and Electromyography Variables Comparing Elders and Stroke Survivors

OBJECTIVES

The objectives of this study are to analyze the relationship between electromyographic variables, tibialis anterior (TA) architecture, and functional variables (torque and kinematic variables) during maximal isometric and isotonic foot dorsiflexion (FD), and to compare the described relationship between stroke survivors (SS) and healthy elders (HE).

METHODS

Twenty-eight participants (14 SS and 14 HE) over 65 years old performed 3 maximal isometric and isotonic FDs parameterized by ultrasound, electromyography (EMG), inertial sensor, and load cell. Common variables (TA) include muscle thickness, pennation angle, muscle activation, and EMG area under the curve. Specific variables include torque for isometric FD, and velocity and displacement for isotonic FD.

RESULTS

There are significant differences in all variables when comparing the 2 groups. Among these differences, all the outcome variables show higher values in the HE group than in the SS group. However, in the 2 dependent variables obtained during isometric FD (median and maximal torques), the independent variables can explain nearly 70% of the variability of the dependent variable, with values of 68.4%-71.9% for SS and 69.1%-70.2% for HE. Similar results were found during isotonic FD.

CONCLUSIONS

Even though the TA of the SS group is capable of generating less force (isometric FD) and is slower (isotonic FD) than that of the HE group, the contribution of the independent variables (muscle activation, pennation angle,and muscle thickness) can explain the same proportion of variability of the dependent variables.

Spatial localization and distribution of the TMS-related 'hotspot' of the tibialis anterior muscle representation in the healthy and post-stroke motor cortex

Transcranial magnetic stimulation (TMS) is a type of noninvasive brain stimulation used to study corticomotor excitability of the intact and injured brain. Identification of muscle representations in the motor cortex is typically done using a procedure called 'hotspotting', which involves establishing the optimal location on the scalp that evokes a maximum TMS response with minimum stimulator intensity. The purpose of this study was to report the hotspot locations for the tibialis anterior (TA) muscle representation in the motor cortex of healthy and post stroke individuals. A retrospective data analyses from 42 stroke participants and 32 healthy participants was conducted for reporting TMS hotspot locations and their spatial patterns. Single pulse TMS, using a 110mm double cone coil, was used to identify the motor representation of the TA. The hotspot locations were represented as x and y-distances from the vertex for each participant. The mediolateral extent of the loci from the vertex (x-coordinate) and anteroposterior extent of the loci from the vertex (y-coordinate) was reported for each hemisphere: non-lesioned (XNLes, YNLes), lesioned (XLes, YLes) and healthy (XH, YH). We found that the mean hotspot loci for TA muscle from the vertex were approximately: 1.29cm lateral and 0.55cm posterior in the non-lesioned hemisphere, 1.25cm lateral and 0.5cm posterior in the lesioned hemisphere and 1.6cm lateral and 0.8cm posterior in the healthy brain. There was no significant difference in the x- and y-coordinates between the lesioned and non-lesioned hemispheres. However, the locations of the XNLes (p=0.01) and XLes (p=0.004) were significantly different from XH. The YNLes and YLes showed no significant differences from YH loci. Analyses of spatial clustering patterns using the Moran's I index showed a negative autocorrelation in stroke participants (NLes: Moran's I=-0.09, p<0.001; Les: Moran's I=-0.14, p=0.002), and a positive autocorrelation in healthy participants (Moran's I=0.16, p<0.001), suggesting that individuals with stroke demonstrated a more dispersed pattern of hotspot locations than healthy individuals. Our results suggest that the hotspot loci show different spatial patterns in healthy and stroke individuals. The hotspot locations from this study has the potential to provide a guideline for optimal stimulation locations for the TA muscle in healthy and post stroke individuals for neuromodulation procedures such as transcranial direct current stimulation.

Neuromuscular function in different stages of sarcopenia

This study applied the screening tool developed by the European Working Group on Sarcopenia in Older People (EWGSOP) on seniors aged over 65years and concurrently tested various laboratory-based indices of neuromuscular function. Twenty-four healthy and independent living older adults (9 men, 15 women) with a mean age of 79.1±5.8years participated. Based on gait speed, handgrip strength and muscle mass all subjects were categorized into one of the three conceptual sarcopenia stages (pre-sarcopenia, sarcopenia, severe sarcopenia). Maximal strength of dorsiflexors in the left leg was measured and voluntary activation was assessed by the interpolated twitch technique. In addition, isometric evoked contractile properties were recorded. Skeletal muscle mass was assessed by ultrasound from nine sites. There were roughly equal number of subjects in each sarcopenic category, and age was not different among the 3 groups. There were no differences in handgrip strength and skeletal muscle mass index among the 3 groups. Gait speed was significantly slower (p<0.01) in the severe sarcopenic subjects compared to the pre-sarcopenic group. With no differences in voluntary activation among the groups, the maximal voluntary contractions (MVCs) for severe sarcopenic subjects were 29% lower (p=0.02) and with 19% slower (p=0.02) voluntary rates of torque development (RTD) compared to sarcopenic subjects. Furthermore, the severe group was 34% lower (p=0.04) with 36% slower (p=0.02) RTD compared to pre-sarcopenic subjects. Peak twitch tension was 54% lower (p<0.01) in the severe group compared with the pre-sarcopenic group. Maximal twitch RTD were 40% (p=0.03) slower for the severe group compared to the sarcopenia group, and 51% slower (p=0.03) compared with the pre-sarcopenia group, but when normalized to peak torques there were no statistical differences. The laboratory tests found neuromuscular differences among the 3 groups which generally supported the classification scheme and helped to illustrate some key factors that could explain differences in functional capacities. These initial findings support the assumption that this categorization is relevant for identifying older adults with different neuromuscular properties. However, further studies are needed to provide more insight into the specific neuromuscular changes in the three sarcopenia stages, and how these changes relate to functional capacity. Such studies could ultimately contribute to identifying optimal interventions to improve neuromuscular functioning.

Soft Tissue Balancing After Partial Foot Amputations

Partial foot amputations have become common procedures for the foot and ankle surgeon as part of a limb salvage practice. These procedures are highly technique driven and there are many complex factors that affect the outcome and longevity. Appropriate surgical planning must be used with every partial foot amputation to ensure a plantigrade foot with the least potential for future breakdown. When performed appropriately, these amputations have great success with lower energy expenditure and decreased mortality compared with below-knee or above-knee amputations.

Isolation, Culture, Functional Assays, and Immunofluorescence of Myofiber-Associated Satellite Cells

Adult skeletal muscle stem cells, termed satellite cells, regenerate and repair the functional contractile cells in adult skeletal muscle called myofibers. Satellite cells reside in a niche between the basal lamina and sarcolemma of myofibers. Isolating single myofibers and their associated satellite cells provides a culture system that partially mimics the in vivo environment. We describe methods for isolating and culturing intact individual myofibers and their associated satellite cells from the mouse extensor digitorum longus muscle. Following dissection and isolation of individual myofibers we provide protocols for myofiber transplantation, satellite cell transfection, immune detection of satellite cell antigens, and assays to examine satellite cell self-renewal and proliferation.

Traumatic avulsion of tibialis anterior following an industrial accident: A case report

INTRODUCTION

Rupture of the tibialis anterior tendon is uncommon and can occur spontaneously or following trauma. If suspected, it should be diagnosed promptly, enabling early surgical management and good restoration of function.

PRESENTATION OF CASE

A 48 year old male sustained a crush injury to his right foot when it became stuck in a vertical industrial fan at work. He attended A & E complaining of swelling of the dorsum of foot. On examination, there was tenderness at the base of the first metatarsal. X-ray revealed an avulsion fracture of the first metatarsal, and MRI showed rupture of tibialis anterior. The patient underwent surgical repair 10 days later, with post-operative management in a non-weight bearing, then weight bearing cast. X-ray at 8 weeks showed that the fracture had healed. The patient had a course of physiotherapy and was followed up at 6 months to assess pain and function.

DISCUSSION

Tibialis anterior rupture should be considered if the history is suggestive, and can be diagnosed clinically based on the triad of a 'pseudotumour' of the ruptured tendon, loss of tendon contour, and reduced dorsiflexion of the ankle. In our case, the avulsion fracture prompted further imaging to confirm the diagnosis and plan surgery. There are various operative technique described in the literature. We used a whip stitch with anchors to reattach the tendon to the base of first metatarsal.

CONCLUSION

A prompt and early diagnosis of surgical repair of tibialis anterior tendon avulsion is important to ensure that the patients return to work as an industrial worker.

Improvement of isometric dorsiflexion protocol for assessment of tibialis anterior muscle strength

It is important to accurately estimate the electromyogram (EMG)/force relationship of triceps surae (TS) muscle for detecting strength deficit of tibalis anterior (TA) muscle. In literature, the protocol for recording EMG and force of dorsiflexion have been described, and the necessity for immobilizing the ankle has been explained. However, there is a significant variability of the results among researchers even though they report the fixation of the ankle.

We have determined that toe extension can cause significant variation in the dorsiflexion force and EMG of TS and this can occur despite following the current guidelines which require immobilizing the ankle. The results also show that there was a large increase in the variability of the force and the RMS of EMG of TS when the toes were not strapped compared with when they were strapped. Thus, with the current guidelines, where there are no instructions regarding the necessity of strapping the toes, the EMG/force relationship of TS could be incorrect and give an inaccurate assessment of the dorsiflexor TA strength.

In summary,

•

Current methodology to estimate the dorsiflexor TA strength with respect to the TS activity, emphasizing on ankle immobilization is insufficient to prevent large variability in the measurements.

•

Toe extension during dorsiflexion was found to be one source of variability in estimating the TA strength.

•

It is recommended that guidelines for recording force and EMG from TA and TS muscles should require the strapping of the toes along with the need for immobilizing the ankle.

Prolonged cycling alters stride time variability and kinematics of a post-cycle transition run in triathletes

Previous studies have employed relatively short cycling protocols to investigate the effect of cycling on muscle activation and kinematics in running. The aim of this study was to investigate the effect of 3h of cycling on stride time variability (STV), stride length, tibialis anterior (TA) activation, and lower limb range of motion (ROM) in a transition run. Eight triathletes completed a run-cycle-run protocol. Data were collected from a pre-cycle run and a transition run after 3h of cycling. STV, stride length and ROM were assessed using three-dimensional motion analysis, and TA activation was recorded using surface electromyography. Results showed that compared with the pre-cycle run triathletes exhibited increased STV (Cohen's d=0.95) and shorter strides (d=0.15) in the transition run (p<0.05). TA activation and ROM did not change. After 10min of transition running, ankle and hip ROM significantly increased (d=0.40 and 0.41 respectively) compared to the beginning of the transition run (p<0.05) but no other changes were observed. The results suggest that locomotor control and kinematics in a transition run are affected by prolonged cycling and stride time variability is potentially a novel method of evaluating the immediate effect of prolonged cycling on the locomotor control of running.

The importance of dynamic ultrasound in the diagnosis of tibialis anterior muscle herniation

Tibialis anterior muscle hernia is a challenging diagnosis. Ultrasound findings generally are negative because patients come to ultrasound study from home when they are at rest. When the operator of ultrasound suspects a muscle hernia, he has to scan the affected limb or the affected organ dynamically at rest and after stressing the limb. Here, we present a case of a 19-year-old dancer with anterior leg mass with negative ultrasonographic findings at rest but was diagnosed with tibialis anterior hernia after stress dynamic ultrasound.

Compensatory strategies during walking in response to excessive muscle co-contraction at the ankle joint

Excessive co-contraction causes inefficient or abnormal movement in several neuromuscular pathologies. How synergistic muscles spanning the ankle, knee and hip adapt to co-contraction of ankle muscles is not well understood. This study aimed to identify the compensation strategies required to retain normal walking with excessive antagonistic ankle muscle co-contraction. Muscle-actuated simulations of normal walking were performed to quantify compensatory mechanisms of ankle and knee muscles during stance in the presence of normal, medium and high levels of co-contraction of antagonistic pairs gastrocnemius+tibialis anterior and soleus+tibialis anterior. The study showed that if co-contraction increases, the synergistic ankle muscles can compensate; with gastrocmemius+tibialis anterior co-contraction, the soleus will increase its contribution to ankle plantarflexion acceleration. At the knee, however, almost all muscles spanning the knee and hip are involved in compensation. We also found that ankle and knee muscles alone can provide sufficient compensation at the ankle joint, but hip muscles must be involved to generate sufficient knee moment. Our findings imply that subjects with a rather high level of dorsiflexor+plantarflexor co-contraction can still perform normal walking. This also suggests that capacity of other lower limb muscles to compensate is important to retain normal walking in co-contracted persons. The compensatory mechanisms can be useful in clinical interpretation of motion analyses, when secondary muscle co-contraction or other deficits may present simultaneously in subjects with motion disorders.

Quantifying the passive stretching response of human tibialis anterior muscle using shear wave elastography

BACKGROUND

Quantifying passive stretching responses of individual muscles helps the diagnosis of muscle disorders and aids the evaluation of surgical/rehabilitation treatments. Utilizing an animal model, we demonstrated that shear elastic modulus measured by supersonic shear wave elastography increases linearly with passive muscle force. This study aimed to use this state-of-the-art technology to study the relationship between shear elastic modulus and ankle dorsi-plantarflexion angle of resting tibialis anterior muscles and extract physiologically meaningful parameters from the elasticity-angle curve to better quantify passive stretching responses.

METHODS

Elasticity measurements were made at resting tibialis anterior of 20 healthy subjects with the ankle positioned from 50° plantarflexion to up to 15° dorsiflexion at every 5° for two cycles. Elasticity-angle data was curve-fitted by optimizing slack angle, slack elasticity, and rate of increase in elasticity within a piecewise exponential model.

FINDINGS

Elasticity-angle data of all subjects were well fitted by the piecewise exponential model with coefficients of determination ranging between 0.973 and 0.995. Mean (SD) of slack angle, slack elasticity, and rate of increase in elasticity were 10.9° (6.3°), 5.8 (1.9) kPa, and 0.0347 (0.0082) respectively. Intraclass correlation coefficients of each parameter were 0.852, 0.942, and 0.936 respectively, indicating excellent test-retest reliability.

INTERPRETATION

This study demonstrated the feasibility of using supersonic shear wave elastography to quantify passive stretching characteristics of individual muscle and provided preliminary normative values of slack angle, slack elasticity, and rate of increase in elasticity for human tibialis anterior muscles. Future studies will investigate diagnostic values of these parameters in clinical applications.

Ultrasound of tibialis anterior muscle and tendon: anatomy, technique of examination, normal and pathologic appearance

Lesions of the tibialis anterior muscle and tendon are not frequently reported in international literature although pathology is not rare. Pathology can be spontaneous, associated with arthropathy or more generalized conditions. Clinical assessment may not be sufficient for distinguishing conditions like tendinopathy, tears, bursitis, etc. Therefore, imaging studies are necessary to plan appropriate therapy. US has a number of advantages, including widespread availability, absence of contraindications and low cost. It can also be used for dynamic studies of the muscle during contraction and relaxation. This article reviews the anatomy of the tibialis anterior, normal variants, the technique used for standard US examination of this muscle and tendon, its normal appearance on US and the sonographic characteristics of the most common lesions that affect it including tips on US-guided injections used for treatment.

Spontaneous locomotor activity in late-stage chicken embryos is modified by stretch of leg muscles

Chicks initiate bilateral alternating steps several days before hatching and adaptively walk within hours of hatching, but emergence of precocious walking skills is not well understood. One of our aims was to determine whether interactions between environment and movement experience prior to hatching are instrumental in establishing precocious motor skills. However, physiological evidence of proprioceptor development in the chick has yet to be established; thus, one goal of this study was to determine when in embryogenesis proprioception circuits can code changes in muscle length. A second goal was to determine whether proprioception circuits can modulate leg muscle activity during repetitive limb movements for stepping (RLMs). We hypothesized that proprioception circuits code changes in muscle length and/or tension, and modulate locomotor circuits producing RLMs in anticipation of adaptive locomotion at hatching. To this end, leg muscle activity and kinematics were recorded in embryos during normal posture and after fitting one ankle with a restraint that supported the limb in an atypical posture. We tested the hypotheses by comparing leg muscle activity during spontaneous RLMs in control posture and ankle extension restraint. The results indicated that proprioceptors detect changes in muscle length and/or muscle tension 3 days before hatching. Ankle extension restraint produced autogenic excitation of the ankle flexor and reciprocal inhibition of the ankle extensor. Restraint also modified knee extensor activity during RLMs 1 day before hatching. We consider the strengths and limitations of these results and propose that proprioception contributes to precocious locomotor development during the final 3 days before hatching.

Three intermittent sessions of cryotherapy reduce the secondary muscle injury in skeletal muscle of rat

Although cryotherapy associated to compression is recommended as immediate treatment after muscle injury, the effect of intermittent sessions of these procedures in the area of secondary muscle injury is not established. This study examined the effect of three sessions of cryotherapy (30 min of ice pack each 2h) and muscle compression (sand pack) in the muscle-injured area. Twenty-four Wistar rats (312 ± 20g) were evaluated. In three groups, the middle belly of tibialis anterior (TA) muscle was injured by a frozen iron bar and received one of the following treatments: a) three sessions of cryotherapy; b) three sessions of compression; c) not treated. An uninjured group received sessions of cryotherapy. Frozen muscles were cross- sectioned (10 µm) and stained for the measurement of injured and uninjured muscle area. Injured muscles submitted to cryotherapy showed the smallest injured area (29.83 ± 6.6%), compared to compressed (39.2 ± 2.8%, p= 0.003) and untreated muscles (41.74 ± 4.0%, p = 0.0008). No difference was found between injured compressed and injured untreated muscles. In conclusion, three intermittent sessions of cryotherapy applied immediately after muscle damage was able to reduce the secondary muscle injury, while only the muscle compression did not provide the same effectiveness. Key PointsThree sessions of cryotherapy (30 min each 2 hours) applied immediately after muscle damage reduce the secondary muscle injury.Sessions of compression applied after muscle damage are not able to reduce the secondary muscle injury.