Foot and Ankle

Background: The purpose of our study was to compare ankle range of motion and stiffness in individuals with and without diabetes mellitus using a reliable and valid technique and to document the effect of knee flexion and severity of pathology on ankle range of motion and stiffness. Methods: Twenty-five individuals with diabetes mellitus and 64 nondiabetic individuals, similar in age and gender profile, participated in this study. Results: Results revealed that individuals with diabetes mellitus had both significantly lower peak dorsiflexion range of motion (5.1 and 11.5 degrees, p < 0.001) and higher passive ankle stiffness (0.016 and 0.008 Nm/kg/degree, p < 0.01) than non-diabetic individuals. In individuals with diabetes mellitus, a positive relationship between glycemic control and duration of diabetes mellitus and ankle stiffness ((r 2 = 0.48 and 0.24 respectively, p < 0.01 for both) was found. Conclusion: While decreased range of motion and increased stiffness in the diabetes mellitus population seem clinically intuitive, as far as we know this is the first study to confirm the concurrent existence of both these findings in the plantarflexors in individuals with diabetes mellitus. We applied a reliable and valid technique, one that allowed control of confounding factors such as knee flexion position and differences in determination of end range of motion, and documented a mean 41% loss in dorsiflexion excursion. Changes in the muscle, stemming from underlying pathology, are hypothesized to account for a significant part of the lost range of motion. Changes in ankle range of motion and stiffness may have important implications in plantar loading and ulcer formation.

Los huesecillos accesorios del pie son variaciones anatómicas normales de infrecuente importancia clínica. Se sitúan en los sitios de los centros de osificación secundarios del tarso y metatarso. Desde su primera descripción en la literatura científica en 1804, el os trigonum ha sido un frecuente tema de debate por diversos aspectos, de la etiología al tratamiento. Presentamos un raro caso de un os trigonum doloroso con hallazgos clínicos más evidentes que lo habitual. El huesecillo fue extirpado mediante cirugía abierta con alivio completo de los síntomas. Se discuten brevemente algunas peculiaridades históricas, el diagnóstico, el diagnóstico diferencial, los hallazgos clínicos y las modalidades terapéuticas.

Background: Tendon transfers are commonly used for correction of pathology or deformity of the foot and ankle. Bioabsorbable implants have been developed as an alternative to metal interference screws. The purpose of this study was to document complications following tendon transfers of the foot and ankle using bioabsorbable poly-L-lactide interference screws. Methods: A retrospective chart review was used to identify patients in whom either of the 2 senior authors had performed a tendon transfer of the foot and ankle using a bioabsorbable interference screw between 1999 and 2005. A minimum of 6 months of follow-up was required for inclusion in the study. In all, 31 patients were identified who met the inclusion criteria with an average follow-up of 75 weeks. All screws were made of poly-L-lactide (PLLA). Results: Complications were identified in 12 (39%) of patients. All of the complications reported were known complications of the tendon transfer procedure itself, and were not directly related to the bioabsorbable screw. Conclusions: Based on these early results, PLLA implants appear safe and effective for tendon transfers of the foot and ankle. However, until long-term outcomes are available, judicious use of these implants is recommended. Level of Evidence: Level IV, retrospective case series.

Ankle impingement syndromes are painful conditions that may complicate ankle trauma and are characterized by chronic, progressive pain, swelling, and limitation of movement. These disorders are subclassified according to anatomical location about the tibiotalar joint. This article reviews the various forms of anterior ankle impingement, detailing the unique clinical features, anatomical considerations, pathoetiology, and imaging findings for each.

Background and Purpose: Spastic cerebral palsy is accompanied with an increase in calf muscles’
spasticity and a decrease in the ankle range of motion. The purpose of the study was to compare
muscle inhibitory with functional corrective Kinesio taping applications on children with spastic
cerebral palsy.
Methods: Thirty two children with spastic cerebral palsy were selected from the outpatient clinic of
the faculty of Physical Therapy Cairo University. Muscle inhibitory and functional corrective Kinesio
taping applications in addition to physical therapy program were applied for three successive
months. Digital Goniometer was used to assess the ankle range of motion pre and post Kinesio tape
applications.
Results: The study revealed that that the functional corrective Kinesio taping is more effective in
increasing ankle range of motion than the muscle inhibitory.
Conclusion: Functional Corrective Kinesio tape application is recommended for increasing ankle
range of motion in children with spastic cerebral palsy.

—Severe injuries of lower extremities often lead to chronic pain and reduced walking abilities. We postulated that measuring free-living gait can provide further information about walking ability in complement to clinical evaluations. We sought to validate a method that characterizes free gaits with a wearable sensor. Over one week, 81 healthy controls (HC) and 66 chronic lower limb pain patients (CLLPP) hospitalized for multidisciplinary rehabilitation wore a simple accelerometer (Actigraph). In the acceleration signals, steady one-minute walks detected numbered 7,835 (5,085 in CLLPP and 2,750 in HC). Five gait quality measures were assessed: movement intensity, cadence, stride regularity, and short-term and long-term local dynamic stability. Gait quality variables differed significantly between CLLPP and HC (4% to 26%). Intraclass correlation coefficients (ICC) revealed moderate to high repeatability (0.71–0.91), which suggests that seven days of measurement are sufficient to assess average gait patterns. Regression analyses showed significant association (R 2 =0.44) between gait quality variables and a clinical evaluation of walking ability, i.e. the 6 minute walk test, Overall, the results show that the method is easy to implement, valid (high concurrent validity), and reliable to assess walking abilities ecologically.

Background: The effect of footwear on the gait of children is poorly understood. This systematic review synthesises the evidence of the biomechanical effects of shoes on children during walking and running. Methods: Study inclusion criteria were: barefoot and shod conditions; healthy children aged ≤ 16 years; sample size of n > 1. Novelty footwear was excluded. Studies were located by online database-searching, hand-searching and contact with experts. Two authors selected studies and assessed study methodology using the Quality Index. Meta-analysis of continuous variables for homogeneous studies was undertaken using the inverse variance approach. Significance level was set at P < 0.05. Heterogeneity was measured by I 2. Where I 2 > 25%, a randomeffects model analysis was used and where I 2 < 25%, a fixed-effects model was used. Results: Eleven studies were included. Sample size ranged from 4-898. Median Quality Index was 20/32 (range 11-27). Five studies randomised shoe order, six studies standardised footwear. Shod walking increased: velocity, step length, step time, base of support, double-support time, stance time, time to toe-off, sagittal tibia-rearfoot range of motion (ROM), sagittal tibia-foot ROM, ankle max-plantarflexion, Ankle ROM, foot lift to max-plantarflexion, 'subtalar' rotation ROM, knee sagittal ROM and tibialis anterior activity. Shod walking decreased: cadence, singlesupport time, ankle max-dorsiflexion, ankle at foot-lift, hallux ROM, arch length change, foot torsion, forefoot supination, forefoot width and midfoot ROM in all planes. Shod running decreased: long axis maximum tibialacceleration, shock-wave transmission as a ratio of maximum tibial-acceleration, ankle plantarflexion at foot strike, knee angular velocity and tibial swing velocity. No variables increased during shod running. Conclusions: Shoes affect the gait of children. With shoes, children walk faster by taking longer steps with greater ankle and knee motion and increased tibialis anterior activity. Shoes reduce foot motion and increase the support phases of the gait cycle. During running, shoes reduce swing phase leg speed, attenuate some shock and encourage a rearfoot strike pattern. The long-term effect of these changes on growth and development are currently unknown. The impact of footwear on gait should be considered when assessing the paediatric patient and evaluating the effect of shoe or in-shoe interventions.

T he Lisfranc joint, aka the tarsal-metatarsal (TMT) joint, marks the transition between the more rigid midfoot and the relatively flexible forefoot. It provides critical stability in maintenance of both the transverse and longitudinal arch of the foot. That stability is derived from both its osseous geometry and complex capsuloligamentous architecture.

Fractures of the lateral and the posterior processes of the talus are uncommon and frequently missed because of a low level of suspicion and difficulty in interpretation on plain radiographs. Missed fractures can lead to persistent pain and reduced function.
Lateral process fractures are usually a consequence of forced dorsiflexion and inversion of fixed pronated foot. These are also commonly known as snowboarder’s fractures.
The posterior process of the talus is composed of medial and lateral tubercles, separated by the groove for the flexor hallucis longus tendon.
The usual mechanism of injury is forced hyperplantarflexion and inversion causing direct compression of the posterior talus, or an avulsion fracture caused by the posterior talofibular ligament. CT scans are helpful in cases of high clinical suspicion.
There is a lack of consensus regarding optimal management of these fractures; however, management depends on the size, location and displacement of the fragment, the degree of cartilage damage and instability of the subtalar joint. Non-operative treatment includes immobilization and protected weight-bearing for six weeks. Surgical treatment includes open reduction and internal fixation or excision of the fragments, depending on the size.
Fractures of the lateral and the posterior processes of the talus are uncommon but important injuries that may result in significant disability in cases of missed diagnosis or delayed or inadequate treatment. Early diagnosis and timely management of these fractures help to avoid long-term complications, including malunion, nonunion or severe subtalar joint osteoarthritis.

The following 4 points were delineated and clarified in my response to Dr Craig's challanges:
(1)  Retention of talar supinatus is the embryological cause of a structurally elevated first metatarsal
(2)  The elevated first metatarsal is a common cause of foot hyperpronation
(3)  A structurally elevated first metatarsal can be stabilized using medial column support
(4)  Prior research projects presented (clinical outcomes) that validate the efficacy of the medial column support insoles

OBJECTIVE: Ankle rigidity is a common musculoskeletal disorder affecting the talocrural joint, which can impair weight-bearing ankle dorsiflexion (WBADF) and daily-life in people with or without history of ankle injuries. Our objective was to compare the immediate effects of efficacy of Mulligan Mobilization with Movement (MWM) and Osteopathic Mobilization (OM) for improving ankle dorsiflexion range of motion (ROM) and musculoarticular stiffness (MAS) in people with chronic ankle dorsiflexion rigidity. DESIGN: A randomized clinical trial with two arms. METHODS: Patients were recruited by word of mouth and via social network as well as posters, and analyzed in the neuro musculoskeletal laboratory of the "Université Catholique de Louvain-la-Neuve", Brussels, Belgium. PARTICIPANTS: 67 men (aged 18-40 years) presenting with potential chronic non-specific and unilateral ankle mobility deficit during WBDF were assessed for eligibility and finally 40 men were included and randomly allocated to single session of either MWM or OM. INTERVENTIONS: Two modalities of manual therapy indicated for hypothetic immediate effects in chronic ankle dorsiflexion stiffness, i.e. MWM and OM, were applied during a single session on included patients. MAIN OUTCOME MEASURES: Comprised blinding measures of MAS with a specific electromechanical device (namely: Lehmann's device) producing passive oscillatory ankle joint dorsiflexion and with clinical measures of WBADF-ROM as well. RESULTS: A two-way ANOVA revealed a non-significant interaction between both techniques and time for all outcome measures. For measures of MAS: elastic-stiffness (p = 0.37), viscous-stiffness (p = 0.83), total-stiffness (p = 0.58). For WBADF-ROM: toe-wall distance (p = 0.58) and angular ROM (p = 0.68). Small effect sizes between groups were determined with Co-hen's d ranging from 0.05 to 0.29. One-way ANOVA demonstrated non-significant difference and small to moderate effects sizes (d = 0.003-0.58) on all outcome measures before and after interventions within both groups. A second two-way ANOVA analyzed the effect of each intervention on the sample categorized according to injury history status, and demonstrated a significant interaction between groups and time only for viscous stiffness (p = 0.04, d = −0.55). CONCLUSION: A single session of MWM and OM targeting the talocrural joint failed to immediately improve all measures in B. Hidalgo et al. / The immediate effects of two manual therapy techniques on ankle MAS and dorsiflexion ROM subjects with chronic ankle dorsiflexion stiffness. Despite this, there was an increase in viscous stiffness in people with history of ankle injury following both manual techniques, the value of which remains unclear even if it might help to prevent future abnormal ankle joint movements.

Background: The aim of this study was to determine whether excessive medial deviation of the first metatarsal (excessive intermetatarsal angle) is present in the initial phase of hallux valgus. Methods: The intermetatarsal angle between the first and second metatarsals (1-2 ...

Background: The peripheral complications of diabetes mellitus remain a significant risk to lower-limb morbidity. In New Zealand, risk of diabetes, comorbidity and lower-limb amputation are highly-differential between demographic groups, particularly ethnicity. There is growing and convincing evidence that the use of pedobarographyor plantar pressure measurementcan usefully inform diabetic foot care, particularly with respect to the prevention of re-ulceration among high-risk patients. Methods: For the current feasibility study, we embedded pedobarographic measurements into three unique diabetic foot clinic settings in the New Zealand context, and collected pedobarographic data from n = 38 patients with diabetes using a platform-based (Novel Emed) and/or in-shoe-based system (Novel Pedar). Our aim was to assess the feasibility of incorporating pedobarographic testing into the clinical care of diabetic feet in New Zealand. Results and Conclusions: We observed a high response rate and positive self-reported experience from participants. As part of our engagement with participants, we observed a high degree of lower-limb morbidity, including current ulceration and chronic foot deformities. The median time for pedobarographic testing (including study introduction and consenting) was 25 min. Despite working with a high-risk population, there were no adverse events in this study. In terms of application of pedobarography as a clinical tool in the New Zealand context, the current feasibility study leads us to believe that there are two avenues that deserve further investigation: a) the use of pedobarography to inform the design and effectiveness of offloading devices among high-risk diabetic patients; and b) the use of pedobarography as a means to increase offloading footwear and/or orthoses compliance among high-risk diabetic patients. Both of these objectives deserve further examination in New Zealand via clinical trial.

Background: Foot health is an important aspect of general health, and it can be maintained and promoted through foot self-care. However, little is known about older people's experiences of caring for their feet. The aim of this study was to gather knowledge about experiences of foot self-care from the perspective of healthy older people in order to improve their welfare and their management of foot health. Methods: A qualitative descriptive design with focus groups was used. Seventeen older people recruited from daytime activity centres participated in the focus groups (n = 4). The data were analysed using inductive content analysis. Results: The participants described their foot self-care as including various activities, but they were hindered by the following factors: physical (e.g. changes in nail structure), external (e.g. seeking help from multi-level professionals) and internal (e.g. related to ageing). Foot self-care was considered to be important, but it was not systematically carried out. The participants thought that health-care professionals neglected patients' feet. Conclusions: Older people use a variety of methods to care for their feet. However, several factors hinder their ability to do so. Older people need advice, education and support to maintain their foot health. Future research is needed to identify effective ways to support older people in foot self-care and improve their welfare as active citizens.

„ Silastic implants for the first metatarsophalangeal joint (MTPJ) have been in use for over 50 years. Initial reports were associated with high failure rates leading to development of new designs that are currently in use. „ The aim of this article is to review the historical evolution and the outcomes of silastic implants for the treatment of end-stage OA of the first MTPJ. Databases were searched for studies reporting the outcomes of silastic implants for the first MTPJ. Various relevant search terminologies were used. Studies reporting the outcomes of metallic implants or arthrodesis were excluded. „ The literature search revealed 522 studies, of which 28 were included. Eight studies used single-stemmed implants and 20 used double-stemmed implants for their patients. Twenty-eight studies had a total of 2354 feet with silastic replacements in 1884 patients (1968 to 2003) with an average age of 53 years and the average follow-up was 85.3 months. There were a total of 5.3% (124 feet) failed prostheses. Improvement in pain was reported in 76.6% (1804 feet) with an average patient satisfaction rate of 84%. Radiological changes around the implants were found to be significantly higher with single-stemmed implants (30.3%) compared to the double-stemmed implants (14.7%) (p < 0.05). „ Significantly more single-stemmed implants failed (11%) than the double-stemmed implants (3.6%) (p < 0.05). Despite the initial reports of failed implants and complications , first-and second-generation silastic implants were associated with high patient satisfaction and pain improvement. Current literature lacks long-term outcomes of implants currently in use.

Avulsion fractures of the anterior inferior tibiofibular ligament from its tibial attachment, Tillaux fractures, are
usually seen in adolescents during the interval of the distal tibial epiphyseal closure. However, this pattern of
fracture is rare in adult patients, because the ligaments will usually fail before the bone fails. Avulsion fracture
of the posterior inferior tibiofibular ligament from its tibial attachment, Volkmann fracture, is the
posterolateral counterpart of a similar injury. In the present study, the cases of 2 adult patients with simultaneous
Tillaux and Volkmann fractures are reported and the mechanism of injury, diagnosis, and treatment
discussed. This fracture pattern is extremely rare and, to the best of our knowledge, has not been previously
reported.

BACKGROUND : Ankle fractures are one of the commonest injuries treated by orthopaedic surgeons today. The incidence of malleolar fractures is estimated to be 125/100,000/year.[5] They are common in younger men and older women. The goals of surgical treatment must include anatomic reduction of articular surfaces, restoring metaphyseal stability , preserving blood supply and allowing early motion. MATERIALS AND METHODS : A prospective study was conducted in the Department of Orthopaedic Surgery, Grant Medical Foundation-Ruby Hall Clinic,India on 26 cases of unstable bimalleolar fractures of ankle joint in patients between the age of 18-60 years who underwent surgical treatment with Open Reduction and Internal Fixation with one third tubular locking plate for lateral malleolar fracture and CC/Malleolar screw(s) for medial malleolar fracture between December 2017-March 2019. These patients were followed for 12 months (minimum for 6 months) and evaluated based on union rate through xray radiograph, any complications (infections, mal/nonunion, stiffness) and functionally by Baird and Jackson ankle scoring system. RESULTS: In our study, majority of the patients were male (65.3%), most of the patients were in the age group of 21-48 years with mean age of 34.5 years. Majority of the patients sustained these injuries following RTA(69.2%). According to Lauge-Hansen classification system, 15 (57.69%) cases had supination external rotation type of injury, 6 (23.07%) cases had pronation external rotation type of injury, 4 (15.38%) cases had supination adduction type of injury and 1 (3.84%) cases had pronation abduction mechanism of injury pattern.3 patients had associated syndesmotic injury. Radiological union was seen at 8 weeks in 4 (15.38%) cases, 10 weeks in 13 (50%) cases, 12 weeks in 5 (19.23%) cases, 14 weeks in 3 (11.53%) cases and 16 weeks in 1 (3.84%) cases. Out of 26 cases, two (7.69%) cases had superficial infection which resolved completely with oral antibiotics and one (3.84%) case had ankle joint stiffness.There were no cases of nonunion or malunion in the present study.As per the Baird Jackson scoring system, 15 (57.7%) cases had excellent results, 7 (26.9%) had good, 2 (7.69%) had fair and 2 (7.69%) of the cases had poor results respectively. CONCLUSION: Open reduction and internal fixation should be the treatment of choice for the unstable bimalleolar fractures, as these surgical methods restores the anatomy, biomechanics and contact loading characteristics of the ankle joint.

The term " ankle impingement " encompasses a broad range of conditions that are typically post-traumatic and often chronic. Various forms of mechanical impingement can result from synovial proliferation, bone spur formation, or ligamentous scarring and hypertrophy. Since symptoms and physical findings can mimic a variety of disorders, accurate diagnosis may remain elusive, and proper effective therapy may be delayed. The objective of this article is to define and elucidate the etiology of the various forms of ankle impingement, clarify the range of associated osseous and soft-tissue pathology, and describe the imaging features and therapeutic options.

Intra-articular fractures of calcaneum are known to be difficult to manage and lead to multiple complications including subtalar arthritis and malunion. However, non-union of calcaneum is rarely encountered. Only a total of six studies reporting on 12 patients could be found on reviewing the available literature (English language only). One such case of non-union of calcaneal fracture and its successful management is being reported in this case report. In addition, extremely limited literature available on calcaneal non-union is also briefly reviewed. Role of subtalar arthrodesis with internal fixation of fracture and bone grafting for successful management of this rare complication is highlighted along with the possibility of under-reporting of this relatively unknown complication.

Submit Manuscript | http://medcraveonline.com MOJ Orthop Rheumatol 2016, 4(1): 00126 of side-effects, namely recurrence of deformity, loss of flexion strength of first MTPJ causing first ray insufficiency, first MTPJ loss of movement, and so on.

Background: In response to the COVID-19 pandemic, populations were advised to remain at home to control viral spread. Government-mandated restrictions on free movement affected individuals’ engagement with physical activity, with reported increases leading to biopsychosocial health benefits and conversely increased sedentary behaviour leading to poorer health. Good foot health is key to enabling physical activity and maximal participation in activities of occupation and daily living.Methods: A population-based cross-sectional study was performed, using a web-based platform. Quantitative and qualitative data were captured through responses to open survey questions. Anybody with a foot health condition was eligible to participate in the online survey. Links were sent through professional networks, support groups and charities, using a snowball strategy to maximise participation.Results: 255 respondents completed the survey. Most (n=193, 75.69%) reported an ongoing foot pain or problem...

The aim of this paper was to create an updated Australian guideline on footwear for people with diabetes. We reviewed new footwear publications, (inter)national guidelines, and consensus expert opinion alongside the 2013 Australian footwear guideline to formulate updated recommendations. We recommend health professionals managing people with diabetes should: (1) Advise people with diabetes to wear footwear that fits, protects and accommodates the shape of their feet. (2) Advise people with diabetes to always wear socks within their footwear, in order to reduce shear and friction. (3) Educate people with diabetes, their relatives and caregivers on the importance of wearing appropriate footwear to prevent foot ulceration. (4) Instruct people with diabetes at intermediate- or high-risk of foot ulceration to obtain footwear from an appropriately trained professional to ensure it fits, protects and accommodates the shape of their feet. (5) Motivate people with diabetes at intermediate- o...

Chronic mid-foot pain have several etiological factors and related treatment protocols. Most of the times, the treatment is limited to supportive and symptomatic therapy. Physical therapy measures are ancillary modalities along with activity modifications. A very localized chronic pain refractory to conservative treatment options warrants imaging studies to delineate underlying pathology. On rare instances very interesting underlying lesions are encountered. We present a case report of recalcitrant pain over medial aspect of foot diagnosed radiologically and managed accordingly.

The treatment of severe rigid neurogenic clubfoot deformities still remains a challenging problem in modern paediatric orthopaedics. In those cases, in spite of being a palliative procedure, talectomy has been advocated for the correction of the deformity thus providing a stable plantigrade foot which allows pain-free walking with standard footwear. Herein, we present the results after talectomy in two patients (brother and sister) affected by a hereditary motor and sensory neuropathy type I, with rigid severe pes equinovarus deformities.

A set of associated left pedal elements of a sauropod dinosaur from the Upper Jurassic Morrison Formation in Weston County, Wyoming, is described here. Several camarasaurids, a nearly complete small brachiosaur, and a small diplodocid have been found at this locality, but none match the exceptionally large size of the pedal elements. Next to the associated pedal elements, an isolated astragalus, phalanx and ungual were found, which match the large metatarsals in size. The elements cannot be ascribed to diplodocids due to the lack of a ventral process of metatarsal I. Moreover, the morphology of metatarsal V has a broad proximal end, with a long and narrow distal shaft, which differs from Camarasaurus. The size of the material and a medially beveled distal articular surface of metatarsal IV imply an identification as a brachiosaurid. This is the largest pes ever reported from a sauropod dinosaur and represents the first confirmed pedal brachiosaur elements from the Late Jurassic of N...

Background: Chronic ankle instability (CAI) may result from repeated, frequent ankle sprains during sports activities. Manual examination for CAI is conducted; however, quantitative methods for the evaluation of CAI have not been established, and the reproducibility of the amount of stress is low. This cross-sectional study aimed to use a stress device and ultrasound for the quantitative evaluation of the change in the length of the anterior talofibular ligament (ATFL) during simulated anterior drawer and ankle inversion stress tests. Methods: Questionnaires were provided to 160 healthy college students (86 men, 74 women; 320 ankles). We extracted two groups from them: control subjects without a history of ankle injury (n = 64 ankles) and subjects with CAI (n = 54 ankles). We calculated the change in the length of the ATFL with anterior drawer and inversion stress tests at ankle joint plantar flexions of 0°, 20°, and 45°using ultrasound images. Results: The anterior length change rates were significantly higher in the CAI group than in the control group at ankle joint plantar flexions of 20°and 45°in men (P < 0.05). The inversion length change rates were significantly higher in the CAI group at ankle joint plantar flexion of 20°in men (P < 0.05). No significant between-group difference in the anterior and inversion length change rates was observed in women. Conclusions: Stress ultrasound revealed greater length changes in the ATFL in the CAI group than in the control group. The stress test may be useful at ankle joint plantar flexion of 20°for men.

Background: Diabetic foot ulcers are frequently related to elevated pressure under a bony prominence. Conservative treatment includes offloading with orthopaedic shoes and custom made orthotics or plaster casts. While casting in plaster is usually effective in achieving primary closure of foot ulcers, recurrence rates are high. Minimally invasive surgical offloading that includes correction of foot deformities has good short and long term results. The surgery alleviates the pressure under the bony prominence, thus enabling prompt ulcer healing, negating the patient's dependence on expensive shoes and orthotics, with a lower chance of recurrence. The purpose of this protocol is to compare offloading surgery (percutaneous flexor tenotomy, mini-invasive floating metatarsal osteotomy or Keller arthroplasty) to non-surgical treatment for patients with diabetic foot ulcers in a semi-crossover designed RCT. Methods: One hundred patients with diabetic neuropathy related foot ulcers (tip of toe ulcers, ulcers under metatarsal heads and ulcers under the hallux interphalangeal joint) will be randomized (2:3) to a surgical offloading procedure or best available non-surgical treatment. Group 1 (surgery) will have surgery within 1 week. Group 2 (controls) will be prescribed an offloading cast applied for up to 12 weeks (based on clinical considerations). Following successful offloading treatment (ulcer closure with complete epithelization) patients will be prescribed orthopaedic shoes and custom made orthotics. If offloading by cast for at least 6 weeks fails, or the ulcer recurs, patients will be offered surgical offloading. Follow-up will take place till 2 years following randomization. Outcome criteria will be time to healing of the primary ulcer (complete epithelization), time to healing of surgical wound, recurrence of ulcer, time to recurrence and complications.

AbstractBackground: Outcomes  of  management  of  high  energy  distal  third  tibial  fractures  are  not  satisfactory and associated with complications. So use of external fixator is increased in recent years for distal third tibia  fractures.  We  intend  to  study  the  utility  of  external  fixators  in  high  energy  distal  third  tibial fractures.Materials  and  Methods: This is retrospective  observational  study included  38 patients who underwent close  reduction  and  external  fixation  with  Augmented  Wagners  externalfixator  or  Aesculap  external fixator(unilateral) or Hybrid external fixator for lower third tibial fractures in between 2009 and 2015.Results: The  Olerud  C  and  Molander  H  ankle  score  was  excellent  in  44.73%(n=17),  good  in  31.57% (n=12), fair in 15.78% (n=6) and poor in 7.89% (n=3). The ankle range of movement was near normal in 94.73% cases except in 2 patients where stiffness was encountered. The average duration ofunion was6months  and  89%(n=34)  of  fractures  united  within  7  months.  P  value  <0.05(0.066)  was  not  considered significant.
Conclusion: External Fixators with or without limited percutaneous internal fixation is a reliable method for  stabilization  of  highenergy (Tscherne 2 and 3, compound) lower third tibial fractures. It’s a good alternative to other methods of fixation in lower third tibia fracture.

Purpose: To compare the effect of static holds and continuous passive motion on stiffness and force relaxation of the soft tissue structures resisting ankle joint dorsiflexion. Methods: This study used a randomized repeated measures trial design. Twenty-four asymptomatic subjects (15 males and 8 females) with a mean age of 26 yr participated. A Kin-Com dynamometer was used to measure the stiffness and force relaxation response of tissues about the ankle joint in response to a plantar flexor stretch. A comparison was made of the response for a 1 ϫ 60-s hold, 2 ϫ 30-s holds, 4 ϫ 15-s holds, and continuous passive motion for 60 s. All subjects undertook all conditions. The main outcome measures were 1) stiffness at the ankle joint as it moved to 80% of the maximum range of dorsiflexion, and 2) the decrease in force at 80% of the maximum range of motion of the ankle joint. Results: Stiffness was decreased significantly (P Ͻ 0.05) for the continuous passive motion condition only. The mean magnitude of the decrease in stiffness was 16%. Across hold times, force decreased significantly (P Ͻ 0.05). Bonferonni contrasts indicated that there was a significant difference (P Ͻ 0.05) between the continuous passive motion condition and all other hold conditions. There were no significant differences (P Ͼ 0.05) between the 4 ϫ 15-s, 2 ϫ 30-s, and 1 ϫ 60-s holds. The magnitude of the decline in force was 10.5%, 21.5%, 21.7%, and 19% for the 0-, 15-, 30-, and 60-s holds, respectively. The greatest decreases in tension were achieved in the first 20 s of a hold. Conclusion: If decreasing stiffness is a key aim of a stretching program, the findings indicate that continuous motion is more effective than holds. In contrast, if relaxation of peak tension is the main aim, then holds are most effective.

The link between joint pain and poor posture is not a new concept. However, this author links the development of poor posture to a specific embryological foot structure, which is biomechanically dysfunctional [hyperpronates]. An innovative foot orthosis is introduced which significantly reduces foot hyperpronation associated with this foot type. The result is visually improved posture and less joint pain.

Morton (1935) describes a foot in which the 1 st metatarsal is shorter than the 2 nd , visually identified as a deep 1 st web space (See Figure 1). Rothbart describes a foot in which the 1 st metatarsal is elevated and inverted, the Rothbart foot structure {RFS} (Travell 1995, Gilmore 1996, Dols 1997, Svae 2000, GRD BioTech Inc 2000). Both authors are describing the same foot structure. Rothbart (1988) demonstrates that it is this elevated position of the 1 st metatarsal that destabilizes {hyperpronates} the walking foot (See Figure 2). Hyperpronation shifts the posture forward. The body&#39;s center of gravity falls to the inside of the medial {inner} malleolus, the knees hyperextend, the pelvis unlevels producing a functional leg length discrepancy, the shoulder protract {become rounded} and the head moves forward relative to the spine, a process termed BioImplosion.

Aim : The aim of the study is to compare immediate weight bearing with below-knee cast or immobilization with plaster splint in 6 weeks in patients after operative treatment for ankle bimalleolar fractures.

Methods : Fifty-three patients with ankle bimalleolar fractures were treated operatively in 2005 to 2010 and then were randomly allocated to two groups. Immediately weight bearing in a below-knee cast (26 patients) and immobilization in a plaster splint for the first six postoperative weeks (27 patients). A mean age 37.9 (min 17; max 72). An average follow-up 26.1 months. (min 14; max 55). All fractures were classified with Lauge-Hansen classification. Functional results of both groups were evaluated with AOFAS for the postoperative one year after surgical treatment.

Results : According to the AOFAS scoring system, results were excellent and good in 17 patients in group 1. On the other hand, results were excellent and good in 14 patients in group 2.

Conclusion : As a result we think that weight bearing protocol should be advantaged for patients with ankle bimalleolar fractures after surgical treatment immediately.

Introduction: Spasticity is one of the main characteristics that define children with spastic cerebral palsy which is specified by hyper-tonia and hyper-reflexia of the muscle. Spastic cerebral palsy children, which clearly accompanied by an increase in soleus muscle activity , shows a limited joints range of motions especially to their ankles dorsiflexion range, affecting functional abilities and standing abilities. Objective: To determine a correlation between soleus muscle activity and ankle range of motion in spastic cerebral palsy children. Participants and methods: the study was carried out on forty eight ankles and soleus muscles of spastic cerebral palsy children selected from the outpatient clinic of the Faculty of physical therapy Cairo University , the children was level II according to Gross Motor Function Classification System and their developmental age ranged from 9 to 12 month according to Peabody developmental motor scale , Hoffman reflex to Muscle response (H/M) ratio was used to asses spasticity of soleus muscle ; Ankle dorsiflexion range of motion (ROM) was measured using digital goniometer. Results: the study indicates that H/M Ratio concerning soleus muscle spasticity has a negative moderate correlation (r =-0.5306; p &amp;lt;0.05) to ankle dorsiflexion ROM. Conclusion and recommendation: Soleus muscle spasticity in spastic cerebral palsy children is correlated to the ankle dorsiflexion ROM in those children, where the higher the spasticity is the more decrease in the dorsiflexion range, so its highly recommended in physical therapy treatment program to link the goal of increasing the ankle range of action to controlling and inhibiting the soleus muscle spasticity. Keywords: Spasticity, Cerebral Palsy, Soleus, Ankle, Children.

Functional ankle instability (FAI) is commonly reported by children and adolescents with Charcot-Marie-Tooth disease (CMT), however,, the specific variables associated with FAI remain unknown. An improved understanding of these variables may suggest interventions to improve ankle stability and possibly prevent the long-term complications associated with ankle instability in this population. The aim of this study was to therefore investigate the relationship between FAI and other functional, structural, anthropometric and demographic characteristics in a cross sectional sample of children and adolescents with CMT. Thirty children and adolescents with CMT aged 7-18 years were recruited from the Peripheral Neuropathy Clinics of a large tertiary paediatric hospital. Measures of FAI were obtained using the Cumberland Ankle Instability Tool (CAIT). Demographic and anthropometric data was also collected. Other variables collected included foot structure (Foot Posture Index), ankle range of...

In this paper, the most common injuries in university beach volleyball players are studied through a 33 participant sample at the University Spanish Championship. Injuries were assessed by means of personal interviews and a validated questionnaire. Results show that the body region with the highest incidence was the ankle (33%), followed by the fingers (18.5%), knees (13.0%), shoulders (11.1%) and back (5.6%). Data was also retrieved about the moment of injury (competition or training), origin (impact or overuse) and characteristic of the injury (new or recurrent injury). Statistical processing of data for establishing significant differences was performed using the Chi-square test. Results established a