Journal of Foot and Ankle Research
Lower limb EMG and ground reaction forces in barefoot and shod gait in participants with diabetic neuropathy
Isabel CN Sacco, Paula MH Akashi and Ewald M Hennig
BMC Musculoskeletal Disorders 2010, 11:24doi:10.1186/1471-2474-11-24 Published: 3 February 2010
Abstract (provisional)
Background It is known that when barefoot, gait biomechanics of diabetic neuropathic patients differ from non-diabetic individuals. However, it is still unknown whether these biomechanical changes are also present during shod gait which is clinically advised for these patients. This study investigated the effect of the participants own shoes on gait biomechanics in diabetic neuropathic individuals compared to barefoot gait patterns and healthy controls.
Methods Ground reaction forces and lower limb EMG activities were analyzed in 21 non-diabetic adults (50.9+/-7.3 yr, 24.3+/-2.6 kg/m2) and 24 diabetic neuropathic participants (55.2+/- 7.9yr, 27.0+/-4.4kg/m2). EMG patterns of vastus lateralis, lateral gastrocnemius and tibialis anterior, along with the vertical and antero-posterior ground reaction forces were studied during shod and barefoot gait.
Results Regardless of the disease, walking with shoes promoted an increase in the first peak vertical force and the peak horizontal propulsive force. Diabetic individuals had a delay in the lateral gastrocnemius EMG activity with no delay in the vastus lateralis. They also demonstrated a higher peak horizontal braking force walking with shoes compared to barefoot. Diabetic participants also had a smaller second peak vertical force in shod gait and a delay in the vastus lateralis EMG activity in barefoot gait compared to controls.
Conclusions The change in plantar sensory information that occurs when wearing shoes revealed a different motor strategy in diabetic individuals. Walking with shoes did not attenuate vertical forces in either group. Though changes in motor strategy were apparent, the biomechanical did not support the argument that the use of shoes contributes to altered motor responses during gait.
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Barefoot running featured in Nature
Foot strike patterns and collision forces in habitually barefoot versus shod runners
Nature 2010 Jan 28;463(7280):531-5.
Lieberman DE, Venkadesan M, Werbel WA, Daoud AI, D'Andrea S, Davis IS, Mang'eni RO, Pitsiladis Y.
Department of Human Evolutionary Biology, 11 Divinity Avenue, Harvard University, Cambridge, Massachusetts 02138, USA. danlieb@fas.harvard.edu
Humans have engaged in endurance running for millions of years, but the modern running shoe was not invented until the 1970s. For most of human evolutionary history, runners were either barefoot or wore minimal footwear such as sandals or moccasins with smaller heels and little cushioning relative to modern running shoes. We wondered how runners coped with the impact caused by the foot colliding with the ground before the invention of the modern shoe. Here we show that habitually barefoot endurance runners often land on the fore-foot (fore-foot strike) before bringing down the heel, but they sometimes land with a flat foot (mid-foot strike) or, less often, on the heel (rear-foot strike). In contrast, habitually shod runners mostly rear-foot strike, facilitated by the elevated and cushioned heel of the modern running shoe. Kinematic and kinetic analyses show that even on hard surfaces, barefoot runners who fore-foot strike generate smaller collision forces than shod rear-foot strikers. This difference results primarily from a more plantarflexed foot at landing and more ankle compliance during impact, decreasing the effective mass of the body that collides with the ground. Fore-foot- and mid-foot-strike gaits were probably more common when humans ran barefoot or in minimal shoes, and may protect the feet and lower limbs from some of the impact-related injuries now experienced by a high percentage of runners.
Accompanying YouTube video:
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Should asymptomatic paediatric flat foot be treated?
ISSN: 1045-7860, Volume 23, Issue 1, January 2010
Asymptomatic Flatfoot In Kids: Should You Treat It?
There continues to be quite a bit of controversy surrounding the treatment of pediatric flatfoot with custom orthotics. Given the continued emphasis on evidence-based medicine, this controversy is largely fueled by the lack of any empiric data to support the use of custom orthotics as a means to prevent future podiatric abnormalities or symptoms. Ron Raducanu, DPM, FACFAS notes that orthotic treatment may help correct pediatric flatfoot and potentially prevent related biomechanical dilemmas as children move into adulthood. Angela Margaret Evans, PhD, GradDipSocSc, DipAppSc(Pod) notes a lack of sufficient clinical evidence for treating asymptomatic flatfoot with orthoses. Read the full paper here
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Diagnostic imaging in gout: open access review
The following paper is now freely available for download at the Arthritis Research & Therapy website. A recent review of novel treatments for gout is also available here.
Gout. Imaging of gout: findings and utility
Arthritis Research & Therapy 2009, 11:232doi:10.1186/ar2687
© 2009 BioMed Central Ltd
Abstract
Imaging is a helpful tool for clinicians to evaluate diseases that induce chronic joint inflammation. Chronic gout is associated with changes in joint structures that may be evaluated with diverse imaging techniques. Plain radiographs show typical changes only in advanced chronic gout. Computed tomography may best evaluate bone changes, whereas magnetic resonance imaging is suitable to evaluate soft tissues, synovial membrane thickness, and inflammatory changes. Ultrasonography is a tool that may be used in the clinical setting, allowing evaluation of cartilage, soft tissues, urate crystal deposition, and synovial membrane inflammation. Also ultrasound-guided puncture may be useful for obtaining samples for crystal observation. Any of these techniques deserve some consideration for feasibility and implementation both in clinical practice and as outcome measures for clinical trials. In clinical practice they may be considered mainly for evaluating the presence and extent of crystal deposition, and structural changes that may impair function or functional outcomes, and also to monitor the response to urate-lowering therapy.
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Oligoarthritis of the foot following influenza B virus infection: case report
Transient oligoarthritis of the lower extremity following influenza B virus infection: case report
Abstract (provisional)
A 12-year-old girl developed influenza B virus infection proven by typical symptoms and detection of the virus in a nasopharyngeal swab by culture and PCR. Two weeks later she developed an otherwise unexplained transient oligoarthritis of small joints of the left foot. Influenza viruses may be a hitherto underappreciated cause of a post-infectious arthritis.
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Tenosynovial giant cell tumors as accidental findings after episodes of distortion of the ankle: two case reports
Abstract
Tenosynovial giant cell tumors are benign tumors of uncertain pathogenesis. They occur in the joints, tendons and synovial bursas. Due to a high recurrence rate of up to 50%, some authors call a giant cell tumor a semimalignant tumor. To date, less than 10 cases of tenosynovial giant cell tumor of the ankle have been published in the international medical literature. In this case report, we present two patients with localized tumors that were detected accidentally after the occurrence of ankle sprains with persisting pain in the joint. The tumors were resected by open marginal surgery and regular follow-up examinations were carried out. We present an unusual occurrence of a tumor along with a possible follow-up strategy, which has not been previously discussed in the international literature.
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Chronic bilateral heel pain in Sever's disease: case report
Chronic bilateral heel pain in a child with Sever disease: case report and review of literature
Fred C Sitati, and John Kingori
Abstract
We are presenting a case report of a 10-year-old male with a 1 year history of bilateral heel pain. Sever disease is self limiting condition of calcaneal apophysis. It is the most common cause of heel pain in the growing child. There is no documented case of this condition in this region. This case highlights the clinical features of this self limiting disorder as seen in this patient and reviews the current literature.
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Forefoot disease activity in rheumatoid arthritis patients in remission
Forefoot disease activity in rheumatoid arthritis patients in remission: results of a cohort study
Marike van der Leeden, Martijn PM Steultjens, Dirkjan van Schaardenburg, Joost Dekker
Arthritis Research & Therapy 2010, 12:R3 (7 January 2010)
Introduction: The aim of our study was to investigate the presence of disease activity in the metatarsophalangeal (MTP) joints of the forefoot in rheumatoid arthritis (RA) patients in remission according to the Disease Activity Score based on 28 joints (DAS28) remission criterion.
Methods: A total of 848 patients with recent-onset RA were included from 1995 through 2007. The DAS28 and pain and swelling of the MTP joints were assessed annually. The data were analyzed using descriptive techniques.
Results: On average 35% of the patients fulfilled the remission criterion of DAS28 < 2.6 during the first eight years of RA. On average 29% of these patients had at least one painful MTP joint, and on average 31% had at least one swollen MTP joint during follow-up. Forty percent, on average, had at least one involved MTP joint (pain and/or swelling).
Conclusions: Painful and/or swollen MTP joints were detected in a substantial proportion of patients classified as being in remission. Therefore, examination of the foot joints - irrespective of the patient's state of remission - seems indicated in order to provide optimal foot care.
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Increased hallux angle in children and its association with insufficient length of footwear
BMC Musculoskeletal Disorders 2009, 10:159doi:10.1186/1471-2474-10-159
Abstract (provisional)
Background
Wearing shoes of insufficient length during childhood has often been cited as leading to deformities of the foot, particularly to the development of hallux valgus disorders. Until now, these assumptions have not been confirmed through scientific research. This study aims to investigate whether this association can be statistically proven and if children who wear shoes of insufficient length actually do have a higher risk of a more pronounced lateral deviation of the hallux.
Methods
858 pre-school children were included in the study. The study sample was stratified by sex, urban/rural areas and Austrian province. The hallux angle and the length of the feet were recorded. The inside length of the children's footwear (indoor shoes worn in pre-school and outdoor shoes) were assessed. Personal data and different anthropometric measurements were taken. The risk of hallux valgus deviation was statistically tested by a stepwise logistic regression analysis and the relative risk (odds ratio) for a hallux angle [greater than or equal to] 4 degrees was calculated.
Results
Exact examinations of the hallux angle could be conducted on a total of 1,579 individual feet. Only 23.9% out of 1,579 feet presented a straight position of the great toe. The others were characterized by lateral deviations (valgus position) at different degrees, equalling 10 degrees or greater in 14.2% of the children's feet. 88.8% of 808 children examined wore indoor footwear that was of insufficient length, and 69.4% of 812 children wore outdoor shoes that were too short. A significant relationship was observed between the lengthwise fit of the shoes and the hallux angle: the shorter the shoe, the higher the value of the hallux angle. The relative risk (odds ratio) of a lateral hallux deviation of [greater than or equal to] 4 degrees in children wearing shoes of insufficient length was significantly increased.
Conclusions
There is a significant relationship between the hallux angle in children and footwear that is too short in length. The fact that the majority of the children examined were wearing shoes of insufficient length makes the issue particularly significant. Our results emphasize the importance of ensuring that children's footwear fits properly.
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Treatment of intra-articular calcaneal fracture with calcium phosphate cement: case report
Cases Journal 2009, 2:9290doi:10.1186/1757-1626-2-9290
Abstract (provisional)
Introduction For decades, open reduction and internal fixation was the surgical treatment of choice for intra-articular calcaneal fractures, either with or without any augmentation. Delayed weight bearing and wound-related complications are still unresolved. Aiming at a minimally invasive therapy with accelerated mobilization, we applied closed reduction and balloon-assisted augmentation with calcium phosphate cement. Case presentation A 45-years-old Greek man with intra-articular calcaneal fracture was treated with closed reduction and balloon assisted augmentation with calcium phosphate cement. Follow-up was performed using the Maryland foot score, plain radiographs and multidirectional computerized tomography. Early full weight-bearing was performed at the end of the first week postoperatively. There was no need for secondary reconstructive procedures at the 2 year follow-up. The patient had minimal problems regarding the pain, subtalar motion and peroneal impingement. There was no significant further collapse of the subtalar calcaneal articular surface radiologically. Conclusions The closed reduction and balloon assisted augmentation with calcium phosphate cement of intra-articular calcaneal fractures is a minimally invasive surgical procedure which led to early full weight bearing, good functional patient outcomes and a low complication rate.
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Closed total talus dislocation without fracture: case report
Closed total talus dislocation without fracture: case report
Cases Journal 2009, 2:9132doi:10.1186/1757-1626-2-9132
Abstract
Total dislocation of the talus from all of its joints is a rare injury specially when the talus and malleoli are not fractured and frequently it is as a result of a high-energy trauma. It usually leads to degenerative changes in neighboring joints and frequently avascular necrosis is a predictable outcome. We present a case of total talus dislocation because of a high-energy trauma in association with other major fractures resulting from a fall from height, but no fracture could be detected in the talus and any of malleols. Closed reduction was unsuccessful and we performed open reduction. At 6 month post operation follow-up, the talus didn't show subluxation and avascular necrosis could not be detected.
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Managing complications of the diabetic foot: full text review paper
Managing complications of the diabetic foot
Kelly Cheer, Cliff Shearman, and Edward B Jude. BMJ 2009;339:b4905, doi: 10.1136/bmj.b4905
The fulltext of this paper can be viewed at the BMJ website.
Posted by Hylton Menz at 15:12 Comments (0)
Handing over the prescription pad
Journal of Foot and Ankle Research will soon be publishing two articles pertaining to non-medical prescribing. Here's a discussion piece from the BMJ on the topic, published on November 27, 2009. An editorial on this topic also featured in the BMJ in April 2, 2009 (link).
Handing over the prescription pad
Nigel Hawkes, freelance journalist
1 London
Despite doctors’ objections, other health professions are getting increasing rights to prescribe. Nigel Hawkes investigates
The entitlement to write prescriptions was once the doctor’s prerogative. It signified knowledge, authority, and the exercise of a power sanctioned by social and professional consent.
Today, nearly 10 years after the NHS Plan promised to expand the role of nurses, prescribing has been dragged from the grasp of a reluctant medical profession. Nurses and pharmacists who are appropriately qualified now have access to the whole of the British National Formulary. Later this year, they will also be permitted to prescribe unlicensed medicines for the first time. Physiotherapists, podiatrists, and radiographers already have some prescribing rights and could soon have more.
This change has happened piecemeal and, in the eyes of many doctors, without adequate safeguards. The profession has opposed every step in the process, many doctors claiming that it is unsafe to allow unqualified people to prescribe powerful medicines on the basis of a few weeks’ training. In consultations, the profession has voted solidly for the slowest possible progress, given that no progress at all was not an option. The British Medical Association reacted with horror when in 2005 plans were published to extend nurse prescribing, demanding a meeting with Patricia Hewitt, then health secretary. One doctor launched a petition (now closed) on the No 10 Downing Street website against nurse prescribing: he attracted 147 signatures.
Unfounded fear
What followed these protests has, however, been an anticlimax. Nurses have assumed their new powers cautiously; pharmacists already knew more about medicines than most doctors. The rush of patients damaged by poor prescribing or by unexpected drug interactions has not occurred. Only a single case of inappropriate prescribing has found its way to the fitness to practise panel of the Nursing and Midwifery Council.
"It’s gone smoothly," says Molly Courtenay, who trained as a nurse and is now professor of clinical practice, prescribing and medicines management at the University of Surrey. "There’s no evidence of nurses making clinically inappropriate decisions or working outside their areas of competence.
"Where doctors know the nurses before they start prescribing, there are no problems. What scares doctors is a nurse arriving who’s already a prescriber. They have a feeling in their heads that the new nurse will lack clinical skills, or work outside her area of competence, or simply intrude on what they feel is medical territory."
Her research, which has been extensive, backs up the view that doctors are happy about nurse prescribers they know but anxious about nurse prescribers in general. In a study carried out in a children’s hospital, she quotes one doctor as saying: "I have absolutely no reservation at all, in the context of my colleague, she is somebody I have known for several years and I trust implicitly, but I think you have got to have that relationship."1
In another study of nurse prescribing in dermatology,2 she quotes a doctor who said he was "phenomenally in favour of nurse prescribing" and then went on: "I would feel very very anxious about high-flying ambitious people who do their nursing and at very early years do this nurse prescribing because, whilst they may be very able, what they have not had is the experience, and that is essential to my mind."
Another doctor in the same study said: "The worry is that they have the whole BNF to prescribe from. Our practice nurses wouldn’t prescribe controlled drugs for terminal care because they haven’t got the experience to do that, although on paper they could. I think that is the sort of worry that the general masses (medical profession as a whole) might feel. You are going to get ‘loose cannons,’ people prescribing too much."
There is, in fact, little evidence of this; rather the opposite. Prescribing nurses can function at two levels, as supplementary or independent prescribers. Supplementary prescribers can prescribe any medicine but it must fall within a clinical management plan agreed in advance with a doctor. Independent prescribers can prescribe any medicine for any condition within their area of competence. The evidence Professor Courtenay has gathered suggests a reluctance, only slowly being overcome, for nurses to move to fully independent prescribing.
"Most nurses are very cautious about writing a prescription out," agrees Bill Beeby, who chairs the prescribing subcommittee of the BMA’s General Practitioners Committee. "Too cautious? Maybe. They’ll take advice and ask, ‘Should I be doing that?’ You say it’s perfectly OK and they go away and get familiarity and into their comfort zone."
The responsibility for any prescriber is the same, Dr Beeby says. "We all have to work within our knowledge and competence. It applies to GPs—we don’t prescribe hospital medicines. As long as nurse prescribers do exactly the same, there are no issues."
There are now around 40 000 prescribing nurses in the UK, out of a total nursing population of 690 000. The majority, around 25 000, are health visitors and district nurses, who can prescribe drugs from the Nurse Prescribers’ Formulary for Community Practitioners, which was first published in 1998 and contains only a handful of medicines. The rest are nurse supplementary prescribers or nurse independent prescribers, who have qualified through a course validated by the Nursing and Midwifery Council. Since 2004 both types qualify through the same course, comprising 26 taught days plus 12 days of learning in practice with a designated doctor. Most work in primary care, but with the expansion of the formulary in 2006 a growing number are found in secondary care.
Responsibility
Who is liable if something goes wrong? The Department of Health’s guidance, issued in 2006, makes it clear that all prescribers are accountable in law for all aspects of their prescribing decisions. "Where a nurse, midwife or pharmacist is appropriately trained and qualified and prescribes as part of their professional duties with the consent of their employer, the employer is held vicariously liable for their actions," it adds.
So where, exactly, does the buck stop? The General Medical Council’s guidance says that even if a prescription is being written by a nurse, the doctor will still be responsible for the overall management of the patient. That means that although a doctor will not be accountable for the decisions and actions of the nurse, he or she must be satisfied that the nurse has the right experience, qualifications, knowledge, and skills.
The Nursing and Midwifery Council recommends that all nurse prescribers have professional indemnity insurance and that those who employ them (in primary care, general practitioners) ensure that this is the case. In addition, the Medical Defence Union says that it is the duty of the employer to check on training, competence, and record keeping, as well as ensuring there is good communication between prescribers to make sure that the correct drugs are prescribed to the right patients.
Potential problems can arise when nurses are uncertain and want to discuss a case with a doctor, who may in turn be reluctant to advise without seeing the patient for themselves. In this case, the defence union says, it is important to keep "accurate and contemporaneous" medical records. Dr Beeby, whose practice has three general practitioners and three nurse prescribers, says: "So long as we all stay in the loop, and fully informed, there should be no problem."
Who benefits?
The motivation for nurse prescribing was quicker access to medicines, increased patient choice, more efficient delivery of services, and better use of nurses’ skills and knowledge. Measuring how far these aims have been achieved is not straightforward, and most of the studies so far are narrative in design, focusing on the experiences of nurses, doctors, and patients without measuring outcomes.
One of the most ambitious was a major study carried out for the Scottish government by a team from the University of Stirling and published in September.3 This combined two patient surveys in 2004 and 2007 with case studies and interviews with nurses, doctors, managers, course tutors, and the public.
The conclusions are positive. Benefits include improving patient access to medicines, better patient care and patient experiences, better professional satisfaction and use of staff time, and the maintenance of public health standards. Doctors found that nurse prescribing was safe, helped patients, and made their own workloads more manageable; rural general practitioners were especially appreciative. The public showed confidence in the nurse prescribing it had experienced.
On the negative side, there had been some administrative delays—including such obvious things as providing prescription pads—and a lack of engagement by management. No medicines management system was in place to track the costs of prescribing or to document benefits. Further research is recommended to monitor prescribing costs and to investigate errors.
The team concludes: "Evidence indicates that in some settings nurse prescribing could be rolled out even further and have a greater beneficial impact if some of the obstacles were removed, if best practice could be more readily exchanged and if communication and support networks could be further facilitated."
Expansion
Where nurses and pharmacists have led, other health professionals are soon expected to follow. Physiotherapists, podiatrists, and radiographers already have supplementary prescribing rights, and all allied health professionals can use patient group directions (see box) with the exception of art therapists, music therapists, and drama therapists. All professions can supply medicines under patient specific directions.
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The Department of Health’s view is that these arrangements do not go far enough. In future, patients will be able to refer themselves to these professionals without the intervention of a doctor, so prescribing that relies on an agreed treatment plan with medical input is inappropriate, argues a report published by the department in July.4
"In many clinical pathways the allied health professional is a key or lead clinician yet they are unable to optimise the effectiveness of patient care because they do not have access to appropriate prescribing mechanisms," the report says. It proposes that two professions with supplementary prescribing rights—physiotherapists and podiatrists—have a strong case for progression to independent prescribing. The case is weaker for radiographers.
Meanwhile, dietitians have a strong case for moving to supplementary prescribing, and speech and language therapists, orthoptists, and occupational therapists may also qualify, it suggests. Orthoptists should be given a list of exemptions and so, possibly, should dietitians.
The complexity of the arrangements confuses many doctors, even those as well informed as Dr Beeby. "I find the labelling confusing," he admits, "the distinctions between supplementary and independent prescribing, for example. So I don’t find it at all surprising that other doctors do."
Although a supporter of nurse prescribers, he has some hesitations about further extending the scheme. "I would be very reluctant to see podiatrists with access to the whole formulary," he said.
By the end of the year, the process will see a further twist as the Medicines and Healthcare Products Regulatory Agency moves to allow independent prescribers to prescribe unlicensed medicines on the same basis as doctors. This has met with mixed feelings. Dr Beeby says that it will lead to greater flexibility in some situations, but other doctors warn that off-label prescribing is a step too far.
Cite this as: BMJ 2009;339:b4835
Competing interests: None declared.
References
- Courtenay M, Carey N. Nurse prescribing by children’s nurses: views of doctors and clinical leads in one specialist children’s hospital. J Clin Nurs 2009;18:2668-75.[CrossRef][Web of Science][Medline]
- Stenner K, Carey N, Courtenay M. Nurse prescribing in dermatology: doctors’ and non-prescribing nurses’ views. J Adv Nurs 2009;65:851-9.[CrossRef][Web of Science][Medline]
- Watterson A, Turner F, Coull A, Murray I, Boreham N. An evaluation of the expansion of nurse prescribing in Scotland. www.scotland.gov.uk/Publications/2009/09/24131739/0.
- Marks D. Allied health professions prescribing and medicines supply mechanisms: scoping project report. 2009. www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_103949.pdf.
Posted by Hylton Menz at 15:05 Comments (0)
Prayer nodules affecting the foot: case report
Habib ur Rehman MBBS, Nabil A. Asfour MD Rehman and Asfour doi: 10.1503/cmaj.090392 A 59-year-old man had bilateral lichenified, crusted and hemorrhagic nodules over the dorsum of the feet and around the lateral malleoli. The nodules were painless, well-circumscribed, hyperpigmented and hyperkeratotic. The patient, a Buddhist monk, spent extended periods of time (sometimes days) in a cross-legged sitting position for meditation (full text...)
Posted by Hylton Menz at 14:42 Comments (0)
Surgical treatment of chronic lateral ankle instability
Journal of Orthopaedic Surgery and Research 2009, 4:41doi:10.1186/1749-799X-4-41
Abstract (provisional)
Ankle sprains are very common injuries seen in the athletic and young population. Majority of patients will improve with a course of rest and physical therapy. However, with conservative management about twenty percent of all patients will go on to develop chronic lateral ankle instability. This manuscript describes our detailed surgical technique of a modification to the original Brostrom procedure using three suture anchors to anatomically reconstruct the lateral ankle ligaments to treat high demand patients who have developed chronic lateral ankle instability. The rationale for this modification along with patient selection and workup are discussed. Both the functional outcomes at the two year follow up along with the complications and the detailed postoperative rehabilitation protocol for the high demand athletes are also presented. This modified Brostrom procedure is shown in both illustrative format and intra-operative photos.
Posted by Hylton Menz at 09:04 Comments (0)