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Journal of Nippon Medical School =... 2024Tarsal tunnel syndrome (TTS) is a common entrapment neuropathy that is sometimes elicited by ganglia in the tarsal tunnel.
BACKGROUND
Tarsal tunnel syndrome (TTS) is a common entrapment neuropathy that is sometimes elicited by ganglia in the tarsal tunnel.
METHODS
Between August 2020 and July 2022, we operated on 117 sides with TTS. This retrospective study examined data from 8 consecutive patients (8 sides: 5 men, 3 women; average age 67.8 years) with an extraneural ganglion in the tarsal tunnel. We investigated the clinical characteristics and surgical outcomes for these patients.
RESULTS
The mass was palpable through the skin in 1 patient, detected intraoperatively in 1 patient, and visualized on MRI scanning in the other 6 patients. Symptoms involved the medial plantar nerve area (n = 5), lateral plantar nerve area (n = 1), and medial and lateral plantar nerve areas (n = 2). The interval between symptom onset and surgery ranged from 4 to 168 months. Adhesion between large (≥20 mm) ganglia and surrounding tissue and nerves was observed intraoperatively in 4 patients. Of the 8 patients, 7 underwent total ganglion resection. There were no surgery-related complications. On their last postoperative visit, 3 patients with a duration of symptoms not exceeding 10 months reported favorable outcomes.
CONCLUSIONS
Because ganglia eliciting TTS are often undetectable by skin palpation, imaging studies may be necessary. Early surgical intervention appears to yield favorable outcomes.
Topics: Male; Humans; Female; Aged; Tarsal Tunnel Syndrome; Retrospective Studies; Magnetic Resonance Imaging; Skin
PubMed: 38462440
DOI: 10.1272/jnms.JNMS.2024_91-203 -
Journal of Orthopaedic Case Reports Feb 2024The main differentials of non-traumatic heel pain are plantar fasciitis (PF), plantar heel fat pad atrophy, worn-out footwear, especially asymmetric wear and tear,...
INTRODUCTION
The main differentials of non-traumatic heel pain are plantar fasciitis (PF), plantar heel fat pad atrophy, worn-out footwear, especially asymmetric wear and tear, hyperuricemia, corns, callosities, tumors of the calcaneum, osteomyelitis, calcaneal stress fractures due to overweight or unaccustomed over usage, radiating pain from S1 nerve root compression, and seronegative spondyloarthropathies. Compression of the tibial nerve or the medial calcaneal nerve at or around the flexor retinaculum is the other possibility. In this case report, we want to highlight a sparsely known pathology, caused due to the entrapment of the first branch of the lateral plantar nerve or inferior calcaneal nerve, also known as Baxter's nerve that may present independently or accompany the common PF. Non-steroidal anti-inflammatory medications or injections of local steroids are typically used for conservative management. However, hydro-dissection or surgical release may be needed in non-responsive cases.
CASE REPORT
We present the case of a 57-year-old female with complaints of chronic pain and tenderness in the middle of the heel radiating laterally. She underwent magnetic resonance imaging that revealed chronic denervation changes in the form of marked atrophy and near complete fatty replacement of abductor digiti minimi muscle suggesting chronic Baxter neuropathy. A mildly thickened and hyperintense plantar fascia adjacent to the calcaneal spur and significant heel fat pad edema were seen too. The patient responded well to a local steroid injection and remains pain-free at the 1-year follow-up.
CONCLUSION
When heel pain is present, Baxter's nerve impingement presents as a challenging clinical diagnosis that may accompany the common PF and is often overlooked. MRI can be used to assess the denervation effects of both the acute and chronic stages of Baxter's nerve impingement by identifying abnormalities of the abductor digiti minimi muscle belly.
PubMed: 38420250
DOI: 10.13107/jocr.2024.v14.i02.4252 -
JBJS Essential Surgical Techniques 2023Painful neuromas of the foot and ankle frequently pose a treatment dilemma because of persistent pain or recurrence after resection. Primary surgical treatment of...
BACKGROUND
Painful neuromas of the foot and ankle frequently pose a treatment dilemma because of persistent pain or recurrence after resection. Primary surgical treatment of painful neuromas includes simple excision with retraction of the residual nerve ending to a less vulnerable location. The use of a collagen conduit for recurrent neuromas is advantageous, particularly in areas with minimal soft-tissue coverage options, and is a technique that has shown 85% patient satisfaction regarding surgical outcomes. Additionally, the use of a collagen conduit limits the need for deep soft-tissue dissection and reduces the morbidity typically associated with nerve burial.
DESCRIPTION
Specific steps include appropriate physical examination, preoperative planning, and supine patient positioning. The patient is placed supine with a lower-extremity bolster under the ipsilateral extremity in order to allow improved visualization of the plantar surface of the foot. A nonsterile tourniquet is placed on the thigh. The incision site is marked out, and a longitudinal plantar incision is made until proximal healthy nerve is identified-typically approximately 1 to 2 cm, but the incision can be extended up to 6 cm. The incision is made between the metatarsals, with blunt dissection carried down to the neuroma. The neuroma is sharply excised distally through healthy nerve, and a whip stitch is placed to facilitate the collagen conduit placement. The collagen conduit is passed dorsally into the intermetatarsal space and secured to the dorsal fascia of the foot. The wound is closed with 3-0 nylon horizontal mattress sutures. Postoperatively, a soft dressing is applied to the operative extremity, and patients are advised to be non-weight-bearing for two weeks. At two weeks, patients begin partial weight-bearing with use of a boot, and physical therapy is initiated. No antibiotics are necessary, and 300 mg of gabapentin is prescribed and tapered off by the six-week follow-up visit. Follow-ups are conducted at 2, 6, 12, 24, and fifty-two weeks. It is necessary to monitor for signs and symptoms of infection, surgical complications, and neuroma recurrence during follow-up appointments.
ALTERNATIVES
Simple excision of the neuroma with proximal burial into muscle or bone is a common surgical technique. However, inadequate resection of the nerve or poor surgical technique can lead to recurrent neuromas. For neuromas not responding to simple excision, other techniques have been utilized, including cauterization, chemical agents, nerve capping, and muscle or bone burial. The results of these techniques have varied, and none has gained clinical superiority over the other.
RATIONALE
A study analyzing the use of collagen conduits for painful neuromas of the foot and ankle has shown this technique to be a safe and successful alternative to the previously discussed methods of resection. That study by Gould et al. found that 85% of patients had a substantial reduction in pain, with mean visual analog scale (VAS) pain scores reducing from 8 to 10 preoperatively to 0 to 4 postoperatively. Moreover, alternative biological conduits, such as the greater saphenous vein, have proven to be costly in time and resources, as this structure is often utilized in cardiovascular bypass surgery and its harvest conveys a risk of iatrogenic nerve injury to the patient.Numerous studies focusing on excision of recurrent Morton neuromas via a plantar approach have found variable success rates. Of the patients surveyed in those studies, 75% reported substantial pain improvement. However, <50% of these queried patients reported complete pain relief. Studies analyzing the dorsal approach for revision Morton neuroma excision found similar success rates. Approximately 78% of patients reported good or excellent postoperative outcomes, and significant improvements were observed in patient postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) scores for pain interference, intensity, and global physical health. One study comparing outcomes following plantar versus dorsal approaches for recurrent Morton neuroma found no significant difference in postoperative patient outcomes. That study suggested that surgeons utilize the approach with which they are most comfortable. Gould et al. reported an 85% success rate with collagen conduit, which was similar to if not slightly improved compared with the other prior studies. The utilization of a collagen conduit technique thus offers comparable patient outcomes for patients with difficult neuromas.
EXPECTED OUTCOMES
Recurrent neuroma resection with the use of a collagen conduit has proven to provide satisfactory patient outcomes regarding pain and neuritis symptoms. The goal of any neuroma resection is to greatly diminish or entirely eliminate nerve pain. Based on the available evidence, there has been no proven clinical superiority of any particular technique over the others. However, in the present example case, the location of the patient's neuroma in this video makes it 85% likely that the patient will report satisfactory outcomes and 50% likely that the patient will be entirely symptom-free. At two weeks postoperatively, the patient reported well controlled pain, absence of burning or tingling sensation, full range of movement in the foot, and intact sensation throughout all major nerve distributions, including the saphenous; superficial peroneal nerve; deep peroneal nerve; and sural, medial, and lateral plantar nerves. However, sensation is absent distal to the site of a neuroma resection.
IMPORTANT TIPS
Careful preoperative planting is of utmost importance.Ruling out other potential pathologies is necessary to ensure proper outcomes.Meticulous dissection should be carried out, with delicate handling of the proximal nerve ending.Excision of the nerve should be done sharply through the healthy portion of the nerve.Appropriate sizing of the nerve conduit (with a commercially available industry sizer) should be performed.The nerve conduit should be passed dorsally and secured to the dorsal fascia without any tension.
ACRONYMS AND ABBREVIATIONS
MRI = magnetic resonance imagingUS = ultrasoundVAS = visual analog scale.
PubMed: 38357467
DOI: 10.2106/JBJS.ST.22.00065 -
Frontiers in Neurology 2024ON-freezing of gait (ON-FOG) in Parkinson's disease (PD), often resistant to medication, is linked to sensory deficits and proprioceptive impairment, and results in...
Comparing the efficacy of therapeutic Thai acupressure on plantar acupoints and laser cane therapy on freezing of gait in Parkinson's disease: a randomized non-inferiority trial.
BACKGROUND
ON-freezing of gait (ON-FOG) in Parkinson's disease (PD), often resistant to medication, is linked to sensory deficits and proprioceptive impairment, and results in falls and reduced life quality. While visual cues from a laser cane (LC), which rapidly accesses the motor cortex, are commonly used to compensate for proprioceptive impairment, increased visual reliance may be affected by disease progression. Emerging evidence suggests that modulation of peripheral sensory processing may alleviate ON-FOG, and therapeutic Thai acupressure (TTA) may be a solution. This study aims to evaluate the effect of TTA in alleviating ON-FOG and compare its effectiveness to LC in patients with PD.
METHODS
This open-label, non-inferiority trial randomized 90 PD patients with ON-FOG equally into three arms: TTA for plantar nerve stimulation for 96 s, LC for visual cueing, and sham control (SC). Stride length was the primary non-inferiority endpoint [non-inferiority margin: lower limit of 95% confidence interval (CI) above -10 cm in mean change difference in pre- and immediately post-intervention in TTA versus LC (one-sided)]. Secondary outcomes included FOG episodes, double support time, velocity, cadence, step length, timed up and go (TUG) test, and visual analog scale (VAS) score.
RESULTS
TTA showed non-inferiority to LC in stride length (mean = -0.7 cm; 95% CI: -6.55; 5.15) (one-sided). The improvements with TTA and LC versus SC were comparable between (mean = 13.11 cm; 95% CI: 7.26; 18.96) and (mean = 13.8 cm; 95% CI: 7.96; 19.65) (one-sided). Secondary outcomes favored TTA and LC over SC with improved FOG, velocity, step length, and VAS scores, while only TTA resulted in improved double support time, cadence, and TUG test results. No complications occurred.
CONCLUSION
The efficacy of TTA, which improves stride length, is non-inferior to that of LC and consequently alleviates FOG comparable to LC. TTA might enhance proprioceptive function and reduce visual dependence. Therefore, TTA, characterized by its non-invasive, simple, and safe techniques, is a potential non-pharmacological alternative for ON-FOG treatment and might enhance overall quality of life. However, further research into the mechanism, efficacy, and utilization of TTA is essential.
CLINICAL TRIAL REGISTRATION
https://www.thaiclinicaltrials.org/show/TCTR20200317001, identifier TCTR20200317001.
PubMed: 38348165
DOI: 10.3389/fneur.2024.1327448 -
BMC Musculoskeletal Disorders Feb 2024Malignant femoral soft tissue tumors are occasionally resected together with the femoral nerves, but this can cause loss of knee extensor muscle activity. To the best of...
BACKGROUND
Malignant femoral soft tissue tumors are occasionally resected together with the femoral nerves, but this can cause loss of knee extensor muscle activity. To the best of our knowledge, no previous reports have detailed the gait analysis of such cases in combination with electromyography. Herein, we report the gait analysis of a patient who underwent left groin synovial sarcoma and left femoral nerve resection 12 years ago.
CASE PRESENTATION
We analyzed the gait of a 38-year-old man who was able to walk unaided after the resection of a synovial sarcoma in the left groin together with the ipsilateral femoral nerve. The muscle activities of the affected medial (MH) and lateral hamstrings (LH), and lateral heads of the gastrocnemius (GL) were increased during 50-75% of the stance phase. The hip flexion angle of the affected limb was smaller, and the ankle plantar flexion angle of the affected limb was larger than that of the non-affected limb. This means that in the affected limb, the hip and ankle angles were adjusted to prevent knee collapse, and the MH, LH, and GL muscles contributed in the mid- and late-stance phases. Moreover, we found that the hamstring and gastrocnemius of the affected limb worked together to keep the ipsilateral knee extended in the mid-stance phase and slightly flexed in the late-stance phase.
CONCLUSIONS
Patients capable of walking after femoral nerve resection may control their hamstrings and gastrocnemius muscles collaboratively to prevent ipsilateral knee collapse in the mid- and late-stance phases.
Topics: Male; Humans; Adult; Femoral Nerve; Gait Analysis; Sarcoma, Synovial; Gait; Walking; Knee Joint; Muscle, Skeletal; Sarcoma; Biomechanical Phenomena
PubMed: 38347547
DOI: 10.1186/s12891-024-07258-8 -
BMC Infectious Diseases Jan 2024Leprosy is a chronic infectious disease caused by Mycobacterium leprae, predominantly affecting the peripheral nerves, resulting in sensory and motor deficits in the...
BACKGROUND
Leprosy is a chronic infectious disease caused by Mycobacterium leprae, predominantly affecting the peripheral nerves, resulting in sensory and motor deficits in the feet. Foot ulcers and imbalances are frequent manifestations in leprosy, often correlating with diminished sensitivity. While clinical scales and monofilament esthesiometers are conventionally utilized to evaluate foot sensitivity and balance in these patients, their discriminatory power is limited and their effectiveness is greatly dependent on the examiner's proficiency. In contrast, baropodometry and posturography offer a more comprehensive evaluation, aiming to preempt potential damage events. This study aimed was to assess the correlation between baropodometry and force plate measurements in leprosy patients and control participants, to improve the prevention and treatment of foot ulcers and complications associated with leprosy.
METHODOLOGY
This cross-sectional study was conducted during 2022 and enrolled 39 participants (22 patients with multibacillary leprosy and 17 non-leprosy controls). Demographic data were collected, and a monofilament esthesiometer was used to assess sensory deficits. In addition, physical examinations and balance and plantar pressure tests were conducted. The Student's t-test was used to compare mean and maximum plantar pressures between groups. For most COP variables, a Mann-Whitney Wilcoxon test was used, except for AP amplitude which was analyzed with the Student's t-test due to its normal distribution. The relationship between foot pressure and balance control was assessed using Spearman's correlation, focusing on areas with significant pressure differences between groups.
PRINCIPAL FINDINGS
Leprosy patients showed increased pressure in forefoot areas (T1, M1, T2-T5, and M2) and decreased pressure in hindfoot regions (MH and LH) compared to controls. These patients also displayed higher AP and ML amplitudes, suggesting poorer COP control. Correlation analyses between the two groups revealed that foot plantar pressures significantly impact balance control. Specifically, increased T1 region pressures correlated with greater sway in balance tasks, while decreased MH region pressures were linked to reduced COP control.
CONCLUSIONS/SIGNIFICANCE
The findings suggest a joint disturbance of plantar pressure distribution and static balance control in leprosy patients. These alterations may increase the risk of tissue injuries, including calluses and deformities, as well as falls.
Topics: Humans; Cross-Sectional Studies; Diabetic Foot; Leprosy, Multibacillary; Foot; Lower Extremity
PubMed: 38267905
DOI: 10.1186/s12879-023-08749-0 -
Exercise, Sport & Movement 2023The purpose of this study was to determine the following in persons with midportion Achilles tendinopathy (AT): 1) maximal strength and power; 2) neural drive during...
INTRODUCTION/PURPOSE
The purpose of this study was to determine the following in persons with midportion Achilles tendinopathy (AT): 1) maximal strength and power; 2) neural drive during maximal contractions and contractile function during electrically evoked resting contractions; and 3) whether pain, neural drive, and contractile mechanisms contribute to differences in maximal strength.
METHODS
Twenty-eight volunteers (14 AT, 14 controls) completed isometric, concentric, and eccentric maximal voluntary contractions (MVCs) of the plantar flexors in a Biodex dynamometer. Supramaximal electrical stimulation of the tibial nerve was performed to quantify neural drive and contractile properties of the plantar flexors. Pain sensitivity was quantified as the pressure-pain thresholds of the Achilles tendon, medial gastrocnemius, and upper trapezius.
RESULTS
There were no differences in plantar flexion strength or power between AT and controls (isometric MVC: = 0.95; dynamic MVC: = 0.99; power: = 0.98), nor were there differences in neural drive and contractile function ( = 0.55 and = 0.06, respectively). However, the mechanisms predicting maximal strength differed between groups: neural drive predicted maximal strength in controls ( = 0.02) and contractile function predicted maximal strength in AT ( = 0.001). Although pain did not mediate these relationships (i.e., between maximal strength and its contributing mechanisms), pressure-pain thresholds at the upper trapezius were higher in AT ( = 0.02), despite being similar at the calf ( = 0.24) and Achilles tendon ( = 0.40).
CONCLUSIONS
There were no deficits in plantar flexion strength or power in persons with AT, whether evaluated isometrically, concentrically, or eccentrically. However, the mechanisms predicting maximal plantar flexor strength differed between groups, and systemic pain sensitivity was diminished in AT.
PubMed: 38222444
DOI: 10.1249/esm.0000000000000017