Plantar fasciitis is diagnosed based on a pathognomonic clinical presentation and physical examination including plantar heel pain with the initial few steps after a period of inactivity. People living with HIV/AIDS, who are taking anti-retroviral medications, often have an associated redistribution of body fat (lipodystrophy). Lipoatrophy of the extremities may involve the heel fat-pad in this population and result in the signs and symptoms of plantar fasciitis. Two cases of plantar heel pain in HIV-associated lipodystrophy are presented to discuss the possible clinical association between the two conditions. Although conservative therapies have limited evidence, they are commonly used and have been seen, clinically, to result in a resolution of symptoms. In the presented cases, the individuals benefited from soft tissue therapy, modalities, activity modification and education on proper footwear. Clinicians should be aware that the association between these two conditions may be a significant cause of morbidity in a population of patients with HIV.
heel pain; lipodystrophy; HIV; chiropractic
The objectives of this study were to investigate the causes of plantar heel pain and find differences in the clinical features of plantar fasciitis (PF) and fat pad atrophy (FPA), which are common causes of plantar heel pain, for use in differential diagnosis.
This retrospective study analyzed the medical records of 250 patients with plantar heel pain at the Foot Clinic of Rehabilitation Medicine at Bundang Jesaeng General Hospital from January to September, 2008.
The subjects used in this study were 114 men and 136 women patients with a mean age of 43.8 years and mean heel pain duration of 13.3 months. Causes of plantar heel pain were PF (53.2%), FPA (14.8%), pes cavus (10.4%), PF with FPA (9.2%), pes planus (4.8%), plantar fibromatosis (4.4%), plantar fascia rupture (1.6%), neuropathy (0.8%), and small shoe syndrome (0.8%). PF and FPA were most frequently diagnosed. First-step pain in the morning, and tenderness on medial calcaneal tuberosity correlated with PF. FPA mainly involved bilateral pain, pain at night, and pain that was aggravated by standing. Heel cord tightness was the most common biomechanical abnormality of the foot. Heel spur was frequently seen in X-rays of patients with PF.
Plantar heel pain can be provoked by PF, FPA, and other causes. Patients with PF or FPA typically show different characteristics in clinical features. Plantar heel pain requires differential diagnosis for appropriate treatment.
Plantar heel pain; Plantar fasciitis; Fat pad atrophy
Ground reaction forces from walking result in stress (pressure) and soft tissue strain at the plantar aspect of the foot. Excessive plantar pressure and tissue strain on the insensate foot may lead to ulceration. Our study investigated the effect of therapeutic footwear and custom-made orthotic inserts on pressure and tissue strain along the second ray of the plantar foot, and how these two variables are associated.
Twenty subjects (mean age 57.3 [SD 9.3], 12 male, 8 female, body mass index 32.5 [SD 7.4]) with diabetes mellitus, peripheral neuropathy, and a history of a plantar ulcer participated. Plantar pressure data were recorded during computed tomography scans for four conditions (barefoot, shoe, shoe+total contact insert, and shoe+total contact insert+metatarsal pad). For each condition tested, tissue strain and plantar pressure were determined at the second metatarsal head and at 15 other points along the second ray.
Differences were noted between the 4 conditions for pressure (p < 0.004) and soft tissue strain (p < 0.042) at the second metatarsal head. Correlation coefficients demonstrated an association between pressure and strain (Barefoot r = 0.81, Shoe r = 0.75, Shoe+total contact insert r = 0.73, and Shoe+total contact insert+metatarsal pad r = 0.44).
Footwear and orthotic devices tested in this study decreased pressure and soft tissue strain at the second ray of the foot, and these two variables were strongly related. A better understanding of the role tissue strain plays in distributing plantar forces may lead to improvements in the design of orthotic devices.
Plantar ulceration; Diabetes mellitus; Metatarsal pad; Total contact insert
The implication of high peak plantar pressure on foot pathology in individuals both with and without diabetes has been recognized. The aim of this study was to investigate and clarify the relationship between increasing body mass and peak and mean plantar pressure in an asymptomatic adult population during walking.
Thirty adults without any relevant medical history, structural foot deformities or foot posture assessed as highly pronated or supinated, and within a normal body mass index range were included in the study. An experimental, same subjects, repeated measures design was used. Peak and mean plantar pressure were evaluated with the F-Scan in-shoe plantar pressure measurement system under four different loading conditions (0, 5, 10, and 15 kg) simulated with a weighted vest. Pressure data were gathered from three stances utilizing the mid-gait protocol.
There were statistically significant increases in peak pressure between the 10 and 15 kg load conditions compared to the control (0 kg) within the heel and second to fifth metatarsal regions. The first metatarsal and hallux regions only displayed statistically significant increases in peak pressure between 15 kg and the control (0 kg). The midfoot and lesser digits regions did not display any statistically significant differences in peak pressure between any load conditions compared to the control (0 kg). The second to fifth metatarsal region displayed statistically significant increases in mean pressure in the 5, 10 and 15 kg groups compared to the control (0 kg). A statistically significant increase in peak pressure between the 15 kg and control (0 kg) group was evident in all other regions.
The relationship between increasing body mass and peak and mean plantar pressure was dependent upon the plantar region. This study provides more detail outlining the response of peak and mean pressure to different loading conditions than previously reported in the literature. Further research including measurement of temporal parameters is warranted.
plantar pressure; body mass index; obesity; diabetes; body weight; distribution
The most common benign tumors of the mesenchyme are the lipomas. Benign fatty tumors can arise in any location in which fat is present. Fibrolipomas are characterised by fat modules. Most patients affected by such tumors are in the fifth or sixth decade of life. When very close to vital structures such as joints, they may cause functional limitations as well as pain. Osseous and chondroid metaplasia can infrequently manifest after chronic persistence. Given the rarity of this condition, a case of a big fibrolipoma of Hoffa's fat pad with osseous and cartilaginous metaplasia is reported. A 44-year-old woman presented with an enlarging soft mass on the right knee in the infrapatellar fat pad. After a thorough preoperative clinical and imaging examination, the mass was removed and sent to laboratory where the diagnosis was put. One year after surgery, both local and general condition of the patient were good and no signs of recurrence were found.
Normal and deformed forefeet have been investigated by cadaver anatomical dissections and experiments, by radiographs, CT and MRI scanning, and by clinical studies. Evidence is presented to show that the skeleton of the foot rests on and is controlled by a multi-segmental ligamentous and fascial tie-bar system. Transversely across the plantar aspect of the forefoot, the plantar plates and the deep transverse metatarsal ligaments form a strong ligamentous structure which prevents undue splaying of the forefoot. Longitudinally, the five digital processes of the deeper layer of the plantar fascia are inserted into the plantar plates and control the longitudinal arch of the foot. It is suggested that many forefoot deformities result from the failure of parts of the tie-bar system and the dynamic effect of displacement of the plantar plates. Understanding this allows a more logical approach to their treatment.
We report the successful arthroscopic treatment of a case of subcalcaneal bursitis with plantar fasciitis. To our knowledge, this is the first report on arthroscopic excision of a subcalcaneal bursa. Right heel pain developed in a 50-year-old woman, without any obvious cause. She reported that the heel pain occurred immediately after waking and that the heel ached when she walked. Magnetic resonance imaging showed an extra-articular, homogeneous, high-intensity lesion in the fat pad adjacent to the calcaneal tubercle on T2-weighted sagittal and coronal images and thickening of the plantar fascia on T2-weighted sagittal images. A diagnosis of a recalcitrant subcalcaneal bursitis with plantar fasciitis was made, and surgery was performed. The arthroscope was placed between the calcaneus and the plantar fascia. With the surgeon viewing from the lateral portal and working from the medial portal, the dorsal surface of the degenerative plantar fascia was debrided and the medial half of the plantar fascia was released, followed by debridement of the subcalcaneal bursal cavity through the incised plantar fascia. Full weight bearing and gait were allowed immediately after the operation. At the latest follow-up, the patient had achieved complete resolution of heel pain without a recurrence of the mass, confirmed by magnetic resonance imaging.
Brace application has been reported to be effective in treating idiopathic adolescent scoliosis. The exact working mechanism of a thoracolumbo spinal orthosis is a result of different mechanisms and is not completely understood. One of the supposed working mechanisms is a direct compressive force working through the brace upon the body and thereby correcting the scoliotic deformity, achieving optimal fit of the individual orthosis. In this study we measured these direct forces exerted by the pads in a Boston brace in 16 patients with idiopathic adolescent scoliosis, using the electronic PEDAR measuring device (Novel, Munich, Germany). This is designed as an in-shoe measuring system consisting of two shoe insoles (size 8 1/2), wired to a computer, recording static and dynamic pressure distribution under the plantar surface of the foot. After positioning the inserts between the lumbar and thoracic pads and the body, we measured the forces acting upon the body in eight different postures. In all positions the mean corrective force through the lumbar brace pad was larger than the mean corrective force over the thoracic brace pad. Some changes in body posture resulted in statistically significant alterations in the exerted forces. There was no significant correlation between the magnitude of the compressive force over the lumbar and thoracic brace-pad and the degree of correction of the major curve. Comparing the corrective forces in a relatively new (<6 months) and old (>6 months) brace, there was no statistically relevant difference, although the corrective force was slightly larger in the new braces. We think that the use of this pressure measurement device is practicable and of value for studies of the working mechanism of brace treatment, and in the future it might be of help in achieving optimal fit of the individual orthosis.
Idiopathic scoliosis Brace treatment Corrective force measurements
Associations of pathophysiologic calf muscle characteristics with functional decline in people with lower extremity peripheral arterial disease (PAD) are unknown.
METHODS AND RESULTS
Three hundred seventy participants with PAD underwent baseline measurement of calf muscle area, density, and percent fat using computed tomography. Participants were followed annually for two years. The outcome of mobility loss was defined as becoming unable to walk ¼ mile or walk up and down one flight of stairs without assistance, among those without baseline mobility limitations. Additional outcomes were ≥ 20% decline in six-minute walk distance and becoming unable to walk for six minutes continuously among participants who walked continuously for six minutes at baseline. Adjusting for age, sex, race, body mass index, the ankle brachial index, smoking, physical activity, relevant medications, and comorbidities, lower calf muscle density (p trend < 0.001) and lower calf muscle area (p trend =0.039) were each associated with increased mobility loss rates. Compared to participants in the highest baseline tertiles, participants in the lowest tertile of calf muscle percent fat had a hazard ratio of 0.18 for incident mobility loss (95% CI = 0.06–0.55, p=0.003), and participants in the lowest tertile of muscle density had a 3.50 hazard ratio for incident mobility loss (95% CI= 1.28–9.57, p=0.015). No significant associations of calf muscle characteristics with six-minute walk outcomes were observed.
Our findings suggest that interventions to prevent mobility loss in PAD should focus on reversing pathophysiologic findings in calf muscle.
Intermittent claudication; mobility; peripheral arterial disease; physical functioning
Diabetic foot disease is characterized by progressive foot deformities that lead to amputation and disabling morbidity. The purpose is to investigate the classification of two distinct phenotypes of mid foot structural polymorphism in individuals using plantar kinetic and pressure distribution and tarsal bone density assessments.
Twenty-two individuals (26 ft) with diabetes mellitus, peripheral neuropathy and at least one mid foot deformity were compared to 29 age-, gender- and race-matched healthy controls (58 ft). Eleven subjects with diabetes mellitus and peripheral neuropathy (11 ft) had lateral deformity; 11 subjects (15 ft) had medial deformity. Each subject had calcaneal bone mineral density and plantar force and pressure assessments walking barefoot over an EMED-ST P-2 platform.
Control subjects had lower mid foot vertical forces and pressures despite significantly higher preferred walking speed. In subjects with diabetes and neuropathy, maximum vertical force was 6-fold greater, force–time integral 9.5-fold greater, peak pressure 6.7-fold higher, pressure–time integral was 9.7-fold greater, contact area 2-fold greater and contact time 1.9-fold higher than controls. Pressure values were larger in involved vs uninvolved (P ≤ 0.05). During stance in the mid foot, subjects with medial column phenotype showed greater pressure in the medial mask; subjects with lateral column phenotype had greater pressures in the lateral mask (P < 0.05). Calcaneal bone density was lower for the deformity foot vs the non-deformity foot; bone mineral density was lower in medial column phenotype vs lateral column phenotype (P = 0.02).
Diabetic foot disease can be classified as stereotypical, structurally-distinct phenotypes of deformities of the medial and lateral columns of the mid foot. Assessments of pedal bone density and plantar mid foot force and pressure during barefoot walking can characterize the structural polymorphic phenotypes and may assist the foot care specialist in clinical decision making.
Mid foot deformity; Plantar pressure; Tarsal bone density
We studied whether lower calf muscle density and poorer upper and lower extremity strength are associated with higher mortality rates in men and women with PAD.
Men and women with lower extremity peripheral arterial disease (PAD) have lower calf muscle density and reduced lower extremity strength compared to individuals without PAD.
At baseline, participants underwent measurement of calf muscle density with computed tomography in addition to knee extension power, and isometric knee extension, plantar flexion, and hand grip strength measures. Participants were followed annually for up to four years. Results are adjusted for age, sex, race, body mass index, the ankle brachial index (ABI), smoking, physical activity, and comorbidities.
Among 434 PAD participants, 103 (24%) died during a mean follow-up of 47.6 months. Lower calf muscle density was associated with higher all-cause mortality (lowest density tertile-hazard ratio (HR)=1.80 (95% Confidence Interval (CI)-1.07-3.03), 2nd tertile-HR=0.91 (95% CI-0.51-1.62); highest density tertile (HR=1.00), P trend=0.020) and higher cardiovascular disease mortality (lowest density tertile-HR=2.39 (95% CI-0.90-6.30), 2nd tertile-HR=0.85 (95% CI-0.27-2.71); highest density tertile (HR=1.00), P trend=0.047). Poorer plantar flexion strength (P trend=0.004), lower baseline leg power (P trend=0.046), and poorer handgrip (P trend=0.005) were associated with higher all-cause mortality.
These data demonstrate that lower calf muscle density and weaker plantar flexion strength, knee extension power, and hand grip are associated with increased mortality in participants with PAD, independently of the ABI and other confounders.
Mortality; intermittent claudication; prognosis; Physical functioning
Rhinoplasty is regarded to be associated with many risks as the expectations of patient and physician are not always corresponding. Besides of postoperative deformities many other risks and complications have to be considered.
Reduction-rhinoplasty e.g. can cause breathing disturbances which are reported in 70% of all revision-rhinoplasty-patients. One has to be aware however that scars and loss of mucosal-sensation can also give the feeling of a “blocked nose”.
The main risks of autogenous transplants are dislocation and resorption, while alloplasts can cause infection and extrusion. In this respect silicone implants can have a complication rate between 5-20%. Less complications are reported with other materials like Gore-Tex.
Complications of skin and soft tissues can be atrophy, fibrosis, numbness, cysts originating from displaced mucosa or subcutaneous granulomas caused by ointment material. Postoperative swelling depends mainly on the osteotomy technique. Percutaneous osteotomies cause less trauma, but may result in visible scars.
Infections are rare but sometimes life-threatening (toxic-shock-syndrome). The risk is higher, when sinus surgery and rhinoplasty are combined. Osteotomies can also cause injuries of the orbital region. Necrosis of eye-lids by infections and blindness by central artery occlusion are known. There are reports on various other risks like rhinoliquorrhea, brain damage, fistulas between sinus-cavernosus and carotid artery, aneurysms and thrombosis of the cavernous sinus. Discoloration of incisors are possible by damage of vessels and nerves. Rhinoplasty can also become a court-case in dissatisfied patients, a situation that may be called a “typical complication of rhinoplasty”. It can be avoided by proper patient selection and consideration of psychological disturbances.
Postoperative deformities are considered as main risks of rhinoplasty, causing revision surgery in 5% to 15% of the cases. The analysis of postoperative deformities allowes the identification of specific risks. The most frequent postoperative deformity is the “pollybeak” when a deep naso-frontal angle, cartilaginous hump and reduced tip projection are present preoperatively. The pollybeak is the indication in about 50% of all revision rhinoplasties. Other frequent postoperative deformities are a pendant and wide nasal tip, retractions of the columella base or irregularities of the nasal dorsum. These deformities are very often combined and caused by a loss of septal support. This is why the stability of the caudal septum in septorhinoplasty is the key for a predictable result. Maintaining the position of the tip and the columella is one of the main issues to avoid typical postoperative deformities.
The risks for rhinoplasty-complications can be reduced with increasing experience. A prerequisite is continuing education and an earnest distinction between complication and mistake.
Paternally inherited inactivating mutations of the GNAS gene have been associated with a rare and disabling genetic disorder, progressive osseous heteroplasia, in which heterotopic ossification occurs within extraskeletal soft tissues, such as skin, subcutaneous fat, and skeletal muscle. This ectopic bone formation is hypothesized to be caused by dysregulated mesenchymal progenitor cell differentiation that affects a bipotential osteogenic-adipogenic lineage cell fate switch. Interestingly, patients with paternally inherited inactivating mutations of GNAS are uniformly lean. Using a mouse model of Gsα-specific exon 1 disruption, we examined whether heterozygous inactivation of Gnas affects adipogenic differentiation of mesenchymal precursor cells from subcutaneous adipose tissues (fat pad). We found that paternally inherited Gsα inactivation (Gsα+/p−) impairs adipogenic differentiation of adipose-derived stromal cells (ASCs). The Gsα+/p− mutation in ASCs also decreased expression of the adipogenic factors CCAAT-enhancer-binding protein (C/EBP)β, C/EBPα, peroxisome proliferator-activated receptor gamma, and adipocyte protein 2. Impaired adipocyte differentiation was rescued by an adenylyl cyclase activator, forskolin, and provided evidence that Gsα-cAMP signals are necessary in early stages of this process. Supporting a role for Gnas in adipogenesis in vivo, fat tissue weight and expression of adipogenic genes from multiple types of adipose tissues from Gsα+/p− mice were significantly decreased. Interestingly, the inhibition of adipogenesis by paternally inherited Gsα mutation also enhances expression of the osteogenic factors, msh homeobox 2, runt-related transcription factor 2, and osteocalcin. These data support the hypothesis that Gsα plays a critical role in regulating the balance between fat and bone determination in soft tissues, a finding that has important implications for a wide variety of disorders of osteogenesis and adipogenesis.
GNAS; Progressive osseous heteroplasia; Heterotopic ossification; Adipogenesis; Differentiation; Stem cells
Previous work using an atomic force microscope in nanoindenter mode indicated that the outer, 10- to 15-μm thick, keratinised layer of tree frog toe pads has a modulus of elasticity equivalent to silicone rubber (5–15 MPa) (Scholz et al. 2009), but gave no information on the physical properties of deeper structures. In this study, micro-indentation is used to measure the stiffness of whole toe pads of the tree frog, Litoria caerulea. We show here that tree frog toe pads are amongst the softest of biological structures (effective elastic modulus 4–25 kPa), and that they exhibit a gradient of stiffness, being stiffest on the outside. This stiffness gradient results from the presence of a dense network of capillaries lying beneath the pad epidermis, which probably has a shock absorbing function. Additionally, we compare the physical properties (elastic modulus, work of adhesion, pull-off force) of the toe pads of immature and adult frogs.
Electronic supplementary material
The online version of this article (doi:10.1007/s00359-011-0658-1) contains supplementary material, which is available to authorized users.
Tree frog; Adhesion; Micro-indentation; Effective elastic modulus; Litoria caerulea
Foot orthoses are often used to treat lower limb injuries associated with excessive pronation. There are many orthotic modifications available for this purpose, with one being the medial heel skive. However, empirical evidence for the mechanical effects of the medial heel skive modification is limited. This study aimed to evaluate the effect that different depths of medial heel skive have on plantar pressures.
Thirty healthy adults (mean age 24 years, range 18–46) with a flat-arched or pronated foot posture and no current foot pain or deformity participated in this study. Using the in-shoe pedar-X® system, plantar pressure data were collected for the rearfoot, midfoot and forefoot while participants walked along an 8 metre walkway wearing a standardised shoe. Experimental conditions included a customised foot orthosis with the following 4 orthotic modifications: (i) no medial heel skive, (ii) a 2 mm medial heel skive, (iii) a 4 mm medial heel skive and (iv) a 6 mm medial heel skive.
Compared to the foot orthosis with no medial heel skive, statistically significant increases in peak pressure were observed at the medial rearfoot – there was a 15% increase (p = 0.001) with the 4 mm skive and a 29% increase (p < 0.001) with the 6 mm skive. No significant change was observed with the 2 mm medial heel skive. With respect to the midfoot and forefoot, there were no significant differences between the orthoses.
This study found that a medial heel skive of 4 mm or 6 mm increases peak pressure under the medial rearfoot in asymptomatic adults with a flat-arched or pronated foot posture. Plantar pressures at the midfoot and forefoot were not altered by a medial heel skive of 2, 4 or 6 mm. These findings provide some evidence for the effects of the medial heel skive orthotic modification.
Foot orthoses; Medial heel skive; Foot pronation; Flat-feet; Plantar pressures
Rationale: The effect of obesity on upper airway soft tissue structure and size was examined in the New Zealand Obese (NZO) mouse and in a control lean mouse, the New Zealand White (NZW).
Objectives: We hypothesized that the NZO mouse has increased volume of neck fat and upper airway soft tissues and decreased pharyngeal airway caliber.
Methods: Pharyngeal airway size, volume of the upper airway soft tissue structures, and distribution of fat in the neck and body were measured using magnetic resonance imaging (MRI). Dynamic MRI was used to examine the differences in upper airway caliber between inspiration and expiration in NZO versus NZW mice.
Measurements and Main Results: The data support the hypothesis that, in obese NZO versus lean NZW mice, airway caliber was significantly smaller (P < 0.03), with greater parapharyngeal fat pad volumes (P < 0.0001) and a greater volume of other upper airway soft tissue structures (tongue, P = 0.003; lateral pharyngeal walls, P = 0.01; soft palate, P = 0.02). Dynamic MRI showed that the airway of the obese NZO mouse dilated during inspiration, whereas in the lean NZW mouse, the upper airway was reduced in size during inspiration.
Conclusions: In addition to the increased volume of pharyngeal soft tissue structures, direct fat deposits within the tongue may contribute to airway compromise in obesity. Pharyngeal airway dilation during inspiration in NZO mice compared with narrowing in NZW mice suggests that airway compromise in obese mice may lead to muscle activation to defend upper airway patency during inspiration.
obstructive sleep apnea; magnetic resonance imaging; body fat distribution; tongue; upper airway
Plantar hyperkeratotic lesions are common in older people and are associated with pain, mobility impairment and functional limitations. However, little has been documented in relation to the frequency or distribution of these lesions. The aim of this study was to document the occurrence of plantar hyperkeratotic lesions and the patterns in which they occur in a random sample of older people.
A medical history questionnaire was administered to a random sample of 301 people living independently in the community (117 men, 184 women) aged between 70 and 95 years (mean 77.2, SD 4.9), who also underwent a clinical assessment of foot problems, including the documentation of plantar lesion locations, toe deformities and the presence and severity of hallux valgus.
Of the 301 participants, 180 (60%) had at least one plantar hyperkeratotic lesion. Those with plantar lesions were more likely to be female (χ2 = 18.75, p < 0.01; OR = 2.86), have moderate to severe hallux valgus (χ2 = 6.15, p < 0.02; OR = 2.95), a larger dorsiflexion range of motion at the ankle (39.4 ± 9.3 vs 36.3 ± 8.4°; t = 2.68, df = 286, p < 0.01), and spent more time on their feet at home (5.1 ± 1.0 vs 4.8 ± 1.3 hours, t = -2.46, df = 299, p = 0.01). No associations were found between the presence of plantar lesions and body mass index, obesity, foot posture, dominant foot or forefoot pain. A total of 53 different lesions patterns were observed, with the most common lesion pattern being "roll-off" hyperkeratosis on the medial aspect of the 1st metatarsophalangeal joint (MPJ), accounting for 12% of all lesion patterns. "Roll-off" lesions under the 1st MPJ and interphalangeal joint were significantly associated with moderate to severe hallux valgus (p < 0.05), whereas lesions under the central MPJs were significantly associated with deformity of the corresponding lesser toe (p < 0.05). Factor analysis indicated that 62% of lesion patterns could be grouped under three broad categories, relating to medial, central and lateral locations.
Plantar hyperkeratotic lesions affect 60% of older people and are associated with female gender, hallux valgus, toe deformity, increased ankle flexibility and time spent on feet, but are not associated with obesity, limb dominance, forefoot pain or foot posture. Although there are a wide range of lesion distribution patterns, most can be classified into medial, central or lateral groups. Further research is required to determine whether these patterns are related to the dynamic function of the foot or other factors such as foot pathology or morphology.
To determine whether lower ankle brachial index (ABI) levels are associated with lower calf skeletal muscle area and higher calf muscle percentage fat in persons with and without lower extremity peripheral arterial disease (PAD).
Three Chicago-area medical centers.
Four hundred thirty-nine persons with PAD (ABI<0.90) and 265 without PAD (ABI 0.90–1.30).
Calf muscle cross-sectional area and the percentage of fat in calf muscle were measured using computed tomography at 66.7% of the distance between the distal and proximal tibia. Physical activity was measured using an accelerometer. Functional measures included the 6-minute walk, 4-meter walking speed, and the Short Physical Performance Battery (SPPB).
Adjusting for age, sex, race, comorbidities, and other potential confounders, lower ABI values were associated with lower calf muscle area (ABI<0.50, 5,193 mm2; ABI 0.50–0.90, 5,536 mm2; ABI 0.91–1.30, 5,941 mm2; P for trend <.001). These significant associations remained after additional adjustment for physical activity. In participants with PAD, lower calf muscle area in the leg with higher ABI was associated with significantly poorer performance in usual- and fast-paced 4-meter walking speed and on the SPPB, adjusting for ABI, physical activity, percentage fat in calf muscle, muscle area in the leg with lower ABI, and other confounders (P<.05 for all comparisons).
These data support the hypothesis that lower extremity ischemia has a direct adverse effect on calf skeletal muscle area. This association may mediate previously established relationships between PAD and functional impairment.
physical functioning; peripheral vascular disease; intermittent claudication; sarcopenia
Blepharochalasis is an uncommon disorder distinguished by recurrent episodes of eyelid oedema in young patients. A hypertrophic form, manifested as fat herniation, and an atrophic form, manifested as fat atrophy, have been described. Ptosis with excellent levator function, laxity of the lateral canthal structures with rounding of the lateral canthal angle, nasal fat pad atrophy, and redundant eyelid skin develop after many episodes of eyelid swelling. Fine wrinkling, atrophy, and telangiectasias characterise the excess eyelid skin. We describe four cases of this syndrome in which external levator aponeurosis tuck, blepharoplasty, lateral canthoplasty, and dermis fat grafts were used to correct atrophic blepharochalasis after the syndrome had run its course.
Previous cadaveric studies have suggested that forefoot deformities at the metatarsophalangeal (MTP) joints in patients with rheumatoid arthritis (RA) might result from the failure of the ligamentous system and displacement of the plantar plates. This study aimed to examine the relationship between plantar plate pathology and the rheumatoid arthritis magnetic resonance imaging score (RAMRIS) of the lesser (second to fifth) MTP joints in patients with RA using high-resolution 3 T magnetic resonance imaging (MRI). In 24 patients with RA, the forefoot was imaged using 3 T MRI. Proton density fat-suppressed, T2-weighted fat-suppressed and T1-weighted post gadolinium sequences were acquired through 96 lesser MTP joints. Images were scored for synovitis, bone marrow oedema and bone erosion using the RAMRIS system and the plantar plates were assessed for pathology. Seventeen females and 7 males with a mean age of 55.5 years (range 37–71) and disease duration of 10.6 years (range 0.6–36) took part in the study. Plantar plate pathology was most frequently demonstrated on MRI at the fifth MTP joint. An association was demonstrated between plantar plate pathology and RAMRIS-reported synovitis, bone marrow oedema and bone erosion at the fourth and fifth MTP joints. In patients with RA, 3 T MRI demonstrates that plantar plate pathology at the lesser MTP joints is associated with features of disease severity. Plantar plate pathology is more common at the fourth and fifth MTP joints in subjects with RA in contrast to the predilection for the second MTP reported previously in subjects without RA.
Forefoot; Magnetic resonance imaging; Metatarsophalangeal joint; Plantar plate; RAMRIS; Rheumatoid arthritis
Transgenic mice overexpressing a constitutively active human TGF-beta1 under control of the rat phosphoenolpyruvate carboxykinase regulatory sequences developed fibrosis of the liver, kidney, and adipose tissue, and exhibited a severe reduction in body fat. Expression of the transgene in hepatocytes resulted in increased collagen deposition, altered lobular organization, increased hepatocyte turnover, and in extreme cases, hemorrhage and thrombosis. Renal expression of the transgene was localized to the proximal tubule epithelium, and was associated with tubulointerstitial fibrosis, characterized by excessive collagen deposition and increased fibronectin and plasminogen activator inhibitor-1 immunoreactivity. Pronounced glomerulosclerosis was evident, and hydronephrosis developed with low penetrance. Expression of TGF-beta1 in white and brown adipose tissue resulted in a lipodystrophy-like syndrome. All white fat depots and brown fat pads were severely reduced in size, and exhibited prominent fibroplasia. This reduction in WAT was due to impaired adipose accretion. Introduction of the transgene into the ob/ob background suppressed the obesity characteristic of this mutation; however, transgenic mutant mice developed severe hepato- and splenomegaly. These studies strengthen the link between TGF-beta1 expression and fibrotic disease, and demonstrate the potency of TGF-beta1 in modulating mesenchymal cell differentiation in vivo.
Resistant clubfoot deformities of the foot and ankle remain a difficult problem even for the most experienced surgeon. We report a series of neglected resistant clubfoot deformities treated by limited surgery and Ilizarov distraction histogenesis.
Materials and Methods:
Twenty one patients with 27 feet having resistant clubfoot deformities were managed by Ilizarov distraction histogenesis from April 2005 to May 2008. The mean age was 12 years (range 8–20 years). A limited soft tissue dissection like percutaneous Achilles sheath tenotomy and plantar fasciotomy were done. Progressive correction of the deformities was achieved through the standard and simple Ilizarov frame construct setting. After removal of Ilizarov frame, a short leg walking cast was used for an additional 6 weeks, followed by an ankle foot orthrosis for 3 months.
The mean followup period was 18.7 months (range 20-36 months). The mean duration of fixator application was 3.6 months (range 3–5 months). At the time of removal of the fixator, a plantigrade foot was achieved in 25 feet and gait was improved in all patients. There was residual varus hind foot deformity in two patients. Out of 27 feet, 3 (11.11%) were rated as excellent, 17 (62.96%) as good, 5 (18.51%) as fair, and 2 (7.40%) as poor according to Reinkerand Carpenter scale. Excellent and good results (74.07%) were considered satisfactory, while fair and poor results (25.92%) were considered unsatisfactory.
The short term clinical and functional results of resistant clubfoot deformities with Ilizarov's external fixator is promising and apparently a good option.
Ilizarov frame; deformities; resistant clubfoot
The human capacity to estimate the magnitude of softness of silicone rubber disks of differing compliance was studied under experimental conditions that altered the mode of contact. Subjects were able to scale softness regardless of whether they (1) actively indented each specimen by tapping or pressing it with the finger pad, (2) received passive indentation of the finger pad by each specimen via a force controlled tactile stimulator, thus eliminating kinesthetic cues, or (3) actively indented each specimen with a stylus that was manipulated either by tapping with one finger, or held by two fingers in a precision grip, thereby removing tactile cues provided by direct mechanical contact between the finger pad and specimen. Ratings of softness were independent of moderate variations in peak compressional force and force-rate. Additionally, functions for scaling softness were affected by the mode of contact; the slopes of the functions were greater in the tasks with a complete complement of compliance cues. When subjects were asked to classify objects as either hard or soft, specimens were classified as soft if the compliance were greater than that of the human finger. This suggests that the classification of softness depends on whether the object conforms to the body, and that tactile information about the spatial profile of object deformation is sufficient for the magnitude scaling of softness. But typically, kinesthetic information about the magnitude of object displacement, along with contact vibratory cues is also used while judging softness especially in the absence of direct skin contact with the object when using a tool.
Compliance; Finger pad; Tool use; Active touch; Passive touch; Psychophysics
Plantar calcaneal spurs are common, however their pathophysiology is poorly understood. This study aimed to evaluate the prevalence and correlates of plantar calcaneal spurs in a large sample of older people.
Weightbearing lateral foot radiographs of 216 people (140 women and 76 men) aged 62 to 94 years (mean age 75.9, SD 6.6) were examined for plantar calcaneal and Achilles tendon spurs. Associations between the presence of spurs and sex, body mass index, radiographic measures of foot posture, self-reported co-morbidities and current or previous heel pain were then explored.
Of the 216 participants, 119 (55%) had at least one plantar calcaneal spur and 103 (48%) had at least one Achilles tendon spur. Those with plantar calcaneal spurs were more likely to have Achilles tendon spurs (odds ratio [OR] = 2.0, 95% confidence interval [CI] 1.2 to 3.5). Prevalence of spurs did not differ according to sex. Participants with plantar calcaneal spurs were more likely to be obese (OR = 7.9, 95% CI 3.6 to 17.0), report osteoarthritis (OR = 2.6, 95% CI 1.6 to 4.8) and have current or previous heel pain (OR = 4.6, 95% CI 2.3 to 9.4). No relationship was found between the presence of calcaneal spurs and radiographic measures of foot posture.
Calcaneal spurs are common in older men and women and are related to obesity, osteoarthritis and current or previous heel pain, but are unrelated to radiographic measurements of foot posture. These findings support the theory that plantar calcaneal spurs may be an adaptive response to vertical compression of the heel rather than longitudinal traction at the calcaneal enthesis.
Various local flaps have been used for reconstruction of developmental and post surgical soft tissue defects of maxillofacial region. They include nasolabial flap, palatal pedicled flap, buccal fat pad, temporalis muscle and fascia flap. An ideal flap for all indications is yet to be found. Our experience with free dermal fat graft in the correction of deformities associated with Parry Romberg syndrome and oral submucous fibrosis is presented.
Soft tissue defects; Dermal fat graft; Parry romberg syndrome; Hemifacial atrophy; Oral submucous fibrosis; Soft tissue reconstruction