Effect of audiological testing on programmable ventriculoperitoneal shunts.

OBJECTIVE: This study aimed at measuring the magnetic field strength of commonly used types of audiological testing equipment and determine their effects on the three most commonly used programmable ventriculoperitoneal (VP) shunts to try and quantify the risk of a VP shunt being reprogrammed during audiological testing. DESIGN: In this in vitro study, magnetic field strength was measured for TDH 39 supra-aural earphones, B71 bone vibrator, ALGO 3i probe, Bio-logic Nav Pro probe, Otodynamics otoport insert earphone and Madsen Zodiac tympanometry probe. STUDY SAMPLE: Magnetic field strength associated with transducers placed on a model of a skulls having implanted Miethke ProGAV 2.0, Medtronic Strata II and Codman Hakim programmable VP shunts was measured. RESULTS: The supra-aural earphones had a magnetic field strength of 14 mT at 0 mm, which dropped to 0 mT at 10 mm away from the transducer. All other equipment had a magnetic field strength of 3.5 mT or less at 0 mm. There was no instance of reprogramming of the shunts by the transducers. CONCLUSIONS: The findings suggest that the risk of inadvertent valve-reprogramming by the transducers is extremely small. However, care should be taken to avoid placing any of the transducers directly over the shunt.

An analysis of the foot in turnout using a dance specific 3D multi-segment foot model.

INTRODUCTION: Recent three-dimensional (3D) kinematic research has revealed foot abduction is the strongest predictor of standing functional and forced turnout postures. However, it is still unknown how the internal foot joints enable a large degree of foot abduction in turnout. The primary purpose of this study was to use a dance specific multi-segment foot model to determine the lower leg and foot contributions to turnout that female university-level ballets use to accentuate their turnout. METHODS: Eighteen female dance students (mean age, 18.8 ± 1.6 years) volunteered for this study. Retro-reflective markers were attached to the dancers' dominant foot. Each dancer performed three repetitions of functional turnout, forced turnout and ten consecutive sautés in first position. Repeated measures ANOVA with Bonferroni adjustments for the multiple comparisons were used to determine the kinematic adjustments, hindfoot eversion, midfoot and forefoot abduction, navicular drop (i.e. lowering of the medial longitudinal arch) and first metatarsophalangeal joint abduction between natural double leg up-right posture and the first position conditions. RESULTS: Hindfoot eversion (4.6°, p < 0.001) and midfoot abduction (2.8°, p < 0.001) significantly increased in functional turnout compared to the natural double leg up-right posture. Thirteen dancers demonstrated increased first metatarsophalangeal joint (MTPJ) abduction in forced turnout, however no statistically significant increase was found. Navicular drop during sautés in first position significantly increased by 11 mm (p < 0.001) compared to the natural double leg up-right posture. CONCLUSION: Our findings suggest dancers do pronate, via hindfoot eversion and midfoot abduction in both functional and forced turnout, however, no immediate association was found between forced turnout and first MTPJ abduction. Foot pronation does play a role in achieving turnout. Further prospective research on in situ measures of the lower limb in turnout and injury surveillance is required to improve our understanding of the normal and abnormal dance biomechanics.

Plantar Pressure Measurements and Geometric Analysis of Patients With and Without Morton's Neuroma.

BACKGROUND: The purpose of this research was to see if there were any differences in peak pressure, contact time, pressure-time integrals, and geometric variables such as forefoot width, foot length, coefficient of spreading, and arch index between subjects with Morton's neuroma (MN) and control subjects. METHODS: Dynamic peak plantar pressure, contact time, pressure-time integral, and geometric data were extracted using the EMED-X platform in 52 subjects with MN and 31 control subjects. Differences in peak pressure, contact time, pressure-time integral, and geometric data between participants with and those without MN were determined using independent-samples t tests. There were no significant differences in age, weight, height, and body mass index between patients with MN and control subjects. RESULTS: There were no significant differences in the peak pressures of all masked areas and pressure-time integrals under metatarsal 2 to 4 heads between patients with MN and control subjects. In addition, no significant differences were observed between patients with MN and control subjects in geometric measurements of forefoot length, width, coefficient of spreading, foot progression angle, and arch index. CONCLUSION: No relationship was found in this study between peak pressure, contact time, and pressure-time integral under the metatarsal heads, forefoot width, foot length, coefficient of spreading, and foot progression angle in a symptomatic MN group compared with a control group. The need to perform osteotomies to treat MN not associated with other lesser metatarsal phalangeal joint pathologies is questionable. LEVEL OF EVIDENCE: Level III, Case-Control Study.

Lower-Leg and Foot Contributions to Turnout in University-Level Female Ballet DancersA Preliminary Investigation.

BACKGROUND: Turnout in ballet is produced through summation of the joint structure characteristics and ranges of motion at the hip, knee, ankle, and foot. Contributions of the hip joint to functional turnout in dancers have received extensive examination, whereas little is known about contributions from the knee, ankle, and foot. The aim of this study was to explore the nonhip components of turnout to dancers' functional turnout in first position by assessing passive external tibiofemoral rotation and active measures of foot pronation, ie, navicular drop and Foot Posture Index. METHODS: Nineteen female university-level dance students aged 16 to 19 years participated in this descriptive correlational study. External tibiofemoral rotation, navicular drop, Foot Posture Index, and functional turnout were measured for the participants' right and left legs. RESULTS: Regression analyses revealed a weak relationship between passive external tibiofemoral rotation and functional turnout. Correlation analysis revealed a moderate negative relationship between passive tibiofemoral external rotation and the Foot Posture Index in functional turnout. CONCLUSIONS: These findings suggest that the lower leg does contribute to dancers' overall position of functional turnout. However, current methods are not useful in predicting a dancer's lower-leg contribution and alignment in functional turnout in first position.

Radiographic Analysis of Feet With and Without Morton's Neuroma.

BACKGROUND: The aim of this research was to investigate the association of various structural measurements of the forefoot with Morton's neuroma (MN). METHODS: Weightbearing anteroposterior and lateral foot radiographs of subjects attending the University of Western Australia (UWA) Podiatry Clinic and the first author's private practice were included in this study. A single assessor measured the following angles: lateral intermetatarsal angle (LIMA), intermetatarsal angle (IMA), hallux valgus angle (HVA), digital divergence between the second and third digits (DD23), digital divergence between the third and fourth digits (DD34) and relative metatarsal lengths of the first to fifth metatarsals (Met1-5), and the effect of MN size as measured by ultrasonograph on digital divergence. Intratester reliability of all radiographic measurements was assessed on all radiographic measurements. The study included 101 subjects, of whom 69 were diagnosed with MN and 32 were control subjects without MN. The mean (± standard deviation) age of MN subjects was 52 (±15) years and for control subjects, 48 (±12) years. RESULTS: When comparing all feet, there were no significant differences in the LIMA, HVA, IMA, digital divergence angles and the relative metatarsal distances between subjects with MN and control subjects. No relationship between MN size and digital divergence was found in either foot, or in either neuroma location. CONCLUSION: We were unable to demonstrate any relationship in this study between radiographic metatarsal length and angular measurements in a symptomatic MN group compared to a control group. In addition, we did not find any correlation between the size of MN as measured from ultrasonographic images and radiographic evidence of digital divergence. LEVEL OF EVIDENCE: Level III, case control study.

The relationship between foot posture index, ankle equinus, body mass index and intermetatarsal neuroma.

BACKGROUND: The main purpose of this study was to investigate the presence of an association between intermetatarsal neuroma and foot type, as measured by the Foot Posture Index. The study also examined whether there was a relationship between foot type and the interspace affected with intermetatarsal neuroma, and whether ankle equinus or body mass index had an effect. METHODS: In total, 100 participants were recruited from The University of Western Australia's Podiatry Clinic, 68 of whom were diagnosed with inter-metatarsal neuroma from 2009 to 2015. There were 32 control participants recruited from 2014 to 2015. The age of subjects was recorded, as were weight and height, which were used to calculate body mass index. The foot posture index and ankle dorsiflexion were measured using standard technique. Independent t-tests and Kruskal-Wallis tests were used to compare differences in foot posture index, body mass index and ankle dorsiflexion between the inter-metatarsal neuroma and control groups. Multivariable logistic regression was also used to model relationships for outcome. RESULTS: The 68 intermetatarsal neuroma subjects had a mean age of 52 years (range 20 to 74 years) and comprised of 56 females and 12 males. The 32 control subjects had a mean age of 49 years (range 24 to 67 years) with 26 females and six males. There were no significant differences between the control and the intermetatarsal neuroma groups with respect to the mean foot posture index scores of the left and right foot (p = 0.21 and 0.87, respectively). Additionally no significant differences were detected between the affected intermetatarsal neuroma interspace and foot posture index (p = 0.27 and 0.47, respectively). There was no significant difference in mean body mass index between the intermetatarsal neuroma (26.9 ± 5.7) and control groups (26.5 ± 4.1) (p = 0.72). There was, however, a significant difference in mean ankle dorsiflexion between the intermetatarsal neuroma and control groups (p < 0.001 for both feet). Logistic regression models, adjusted for age, sex, foot posture index and body mass index estimated that the odds of having an intermetatarsal neuroma in the right foot increased by 61% (OR 1.61; 95% CI 1.32-1.96) with each one degree reduction of ankle dorsiflexion, and in the left foot by 43% (OR 1.43; 95% CI 1.22-1.69). CONCLUSION: No relationships were found between foot posture index and body mass index with intermetatarsal neuroma, or between foot posture index and the interspaces affected. However, a strong association was demonstrated between the presence of intermetatarsal neuroma and a restriction of ankle dorsiflexion.

Radiographic Measurements of the Affected and Unaffected Feet in Patients with Unilateral Hallux Limitus A Case-Control Pilot Study.

BACKGROUND: Controversy exists regarding the structural and functional causes of hallux limitus, including metatarsus primus elevatus, a long first metatarsal, first-ray hypermobility, the shape of the first metatarsal head, and the presence of hallux interphalangeus. Some articles have reported on the radiographic evaluation of these measurements in feet affected by hallux limitus, but no study has directly compared the affected and unaffected feet in patients with unilateral hallux limitus. This case-control pilot study aimed to establish whether any such differences exist. METHODS: Dorsoplantar and lateral weightbearing radiographs of both feet in 30 patients with unilateral hallux limitus were assessed for grade of disease, lateral intermetatarsal angle, metatarsal protrusion distance, plantar gapping at the first metatarsocuneiform joint, metatarsal head shape, and hallux abductus interphalangeus angle. Data analysis was performed using a statistical software program. RESULTS: Mean radiographic measurements for affected and unaffected feet demonstrated that metatarsus primus elevatus, a short first metatarsal, first-ray hypermobility, a flat metatarsal head shape, and hallux interphalangeus were prevalent in both feet. There was no statistically significant difference between feet for any of the radiographic parameters measured (Mann-Whitney U tests, independent-samples t tests, and Pearson χ(2) tests: P > .05). CONCLUSIONS: No significant differences exist in the presence of the structural risk factors examined between affected and unaffected feet in patients with unilateral hallux limitus. The influence of other intrinsic factors, including footedness and family history, should be investigated further.

Erratum to: Effectiveness and safety of prolotherapy injections for management of lower limb tendinopathy and fasciopathy: a systematic review.

[This corrects the article DOI: 10.1186/s13047-015-0114-5.].

Effectiveness and safety of prolotherapy injections for management of lower limb tendinopathy and fasciopathy: a systematic review.

INTRODUCTION: The aim of this review was to identify and evaluate existing research to determine the clinical effectiveness and safety of prolotherapy injections for treatment of lower limb tendinopathy and fasciopathy. REVIEW: Nine databases were searched (Medline, Science Direct, AMED, Australian Medical Index, APAIS-Health, ATSIhealth, EMBASE, Web of Science, OneSearch) without language, publication or data restrictions for all relevant articles between January 1960 and September 2014. All prospective randomised and non-randomised trials, cohort studies, case-series, cross-sectional studies and controlled trials assessing the effectiveness of one or more prolotherapy injections for tendinopathy or fasciopathy at or below the superior aspect of the tibia/fibula were included. Methodological quality of studies was determined using a modified evaluation tool developed by the Cochrane Musculoskeletal Injuries Group. Data analysis was carried out to determine the mean change of outcome measure scores from baseline to final follow-up for trials with no comparative group, and for randomised controlled trials, standardised mean differences between intervention groups were calculated. Pooled SMD data were calculated where possible to determine the statistical heterogeneity and overall effect for short-, intermediate- and long-term data. Adverse events were also reported. Two hundred and three studies were identified, eight of which met the inclusion criteria. These were then grouped according to tendinopathy or fasciopathy being treated with prolotherapy injections: Achilles tendinopathy, plantar fasciopathy and Osgood-Schlatter disease. The methodological quality of the eight included studies was generally poor, particularly in regards to allocation concealment, intention to treat analysis and blinding procedures. Results of the analysis provide limited support for the hypothesis that prolotherapy is effective in both reducing pain and improving function for lower limb tendinopathy and fasciopathy, with no study reporting a mean negative or non-significant outcome following prolotherapy injection. The analysis also suggests prolotherapy injections provide equal or superior short-, intermediate- and long-term results to alternative treatment modalities, including eccentric loading exercises forAchilles tendinopathy, platelet-rich plasma for plantar fasciopathy and usual care or lignocaine injections for Osgood-Schlatter disease. No adverse events following prolotherapy injections were reported in any study in this review. CONCLUSIONS: The conclusions of this review were derived from the best available scientific evidence. It is intended that the results of this study will assist clinical decision-making by practitioners. The results of this review found limited evidence that prolotherapy injections are a safe and effective treatment for Achilles tendinopathy, plantar fasciopathy and Osgood-Schlatter disease, however more robust research using large, methodologically-sound randomised controlled trials is required to substantiate these findings.

Ingrown toenails: the role of the GP.

BACKGROUND: An ingrown toenail or onychocryptosis may occur at any age and is the mostly commonly encountered toenail problem likely to be seen in general practice. OBJECTIVE: This article will discuss the common surgical approaches available for the management of an ingrown toenail. DISCUSSION: Ingrown toenail can be a painful condition that can become infected and may require surgical treatment. The epidemiology of onychocryptosis is difficult to determine as it is often considered to be a minor medical problem and as such has been some-what neglected in the literature. The few studies that have been conducted suggest a slightly higher male-to-female ratio, particularly in the 14-25 age group,4 but it can affect patients of any age. There are multiple reasons why an ingrown toenail will develop, including improper nail cutting technique, tight-fitting footwear, trauma, anatomical factors such as thickening of the nail plate, pincer-shaped toenail, pressure from abutting digits caused by hallux valgus or lesser toe deformities, the presence of a subungual exostosis and, occasionally, the use of isotretinoin in the treatment of severe acne.

Description of total population hospital admissions for Morton's metatarsalgia in Australia.

BACKGROUND: Morton's metatarsalgia is a painful perineural fibroma of a plantar nerve, most commonly of the second or third intermetatarsal spaces of the forefoot. The aim of this study was to investigate hospital admissions with a diagnosis of Morton's metatarsalgia in the Australian population from 1998 to 2008. METHODS: Data regarding admissions with a diagnosis code of ICD-10 G57.6 were extracted from the Australian Institute of Health and Welfare databases of hospital morbidity from 1998 to 2008. The event of interest was an admission with ICD-10 G57.6 (Morton's metatarsalgia). The explanatory variables included sex and age group. Rates were calculated using the estimated resident population counts to determine denominators. RESULTS: Morton's metatarsalgia admissions were almost three-fold higher for women in the population compared to men. The rate of admissions for Morton's metatarsalgia was the highest for the total population in the 55- to 59-year-old age group. Among women admitted for Morton's metatarsalgia, the highest rate was in the 50- to 54-year-old age group; among men, the highest rate was in the slightly older 55- to 59-year-old age category. CONCLUSIONS: Population-level information on admissions for Morton's metatarsalgia show that admissions were three times higher among women compared to men. The highest admission rate was in the 50- to 55-year-old age group.

Analysis of dynamic angle of gait and radiographic features in subjects with hallux abducto valgus and hallux limitus.

BACKGROUND: Hallux abducto valgus and hallux limitus are two commonly encountered foot deformities causing altered structure and function of the first metatarsophalangeal joint and subsequent compensatory mechanisms. This study was undertaken to determine the relationships between these two deformities and transverse plane position of the foot, or angle of gait, and several radiographic angular and linear parameters with established reliability. METHODS: A convenience sample of 23 subjects with hallux abducto valgus, 22 subjects with hallux limitus, and 20 control subjects was used. Radiographic parameters were standardized weightbearing views and included lateral stressed dorsiflexion of the first metatarsophalangeal joint, composite, dorsoplantar, and lateral views. Angle of gait was obtained from powdered footprints recorded on paper. Two left and two right footprints identified on each trial were used to calculate angle of gait. RESULTS: The findings of the study suggest that an association between angle of gait and the presence of hallux abducto valgus or hallux limitus does not exist. Possible explanations may relate to the large variability of normal angle of gait, the need to identify factors extrinsic to the foot capable of affecting transverse plane orientation of the foot, and the addition of information relating to symptoms. CONCLUSIONS: In this study, the presence of hallux abducto valgus or hallux limitus did not correspond to an association with a particular angle of gait. Length and elevation of the first metatarsal were associated in subjects with hallux abducto valgus and hallux limitus.

Plantar pressure and radiographic changes to the forefoot after the Austin bunionectomy.

We describe the effects of the Austin bunionectomy on plantar pressure distribution and radiographic measurements in the forefoot in 31 subjects (44 feet) with mild-to-moderate hallux valgus deformity and 36 control subjects (36 feet). Plantar pressure measurements before and 24 months after surgery showed peak pressure beneath the hallux reduced to normal values. Peak pressure measurements beneath the first, second, and third metatarsal heads in hallux valgus feet were relatively unchanged after surgery and remained higher than normal values. The operation produced significant decreases in mean preoperative radiographic measurements of hallux abductus, metatarsus primus varus, and first metatarsal protrusion distance in these patients to below-normal values.

Radiographic investigation of angular and linear measurements including first metatarsophalangeal joint dorsiflexion and rearfoot to forefoot axis angle.

This study investigated intra- and inter-rater reliability of several radiographic angular and linear parameters using 6 subjects. Using standard weight-bearing radiographs, the following measurements were performed: first metatarsal protrusion distance, hallux abductus, first intermetatarsal, calcaneal inclination and lateral intermetatarsal angles. Measurement of lateral stressed dorsiflexion of the first metatarsophalangeal joint and the rearfoot-to-forefoot-axis angle taken using a composite view were also obtained. All parameters were measured independently by 2 raters, and measurements were repeated on 3 separate occasions at weekly intervals. Intrarater reliability of radiographic measurements ranged between R = 0.65-1.00 for lateral stressed dorsiflexion, and between R = 0.91 and 0.99 for the rearfoot to forefoot axis angle. Inter-rater reliability of radiographic measurements ranged from R = 0.82-0.99. Specifically, lateral stressed dorsiflexion showed R = 0.87 with a mean difference of -1.47 (confidence interval [CI]: -3.42, 0.47), indicating no significant difference ( t = 1.54, P = 0.13). The rearfoot-to-forefoot-axis angle showed R = 0.92 with a mean difference of -0.15 (CI: -1.05, 0.74), indicating no significant difference ( t = 0.35, P = 0.73). The 7 angular and linear measurements chosen demonstrated high inter- and intrarater reliability. These results indicate that weight-bearing radiographic first metatarsophalangeal joint dorsiflexion using the lateral stressed dorsiflexion view, and measurement of the rearfoot-to-forefoot-axis angle using a composite view could be measured reliably within and between raters.

Plantar pressure and joint motion after the Youngswick procedure for hallux limitus.

The effects of the Youngswick osteotomy on plantar peak pressure distribution in the forefoot are presented for 17 patients (23 feet) with mild-to-moderate hallux limitus deformity and 23 control subjects (23 feet). During 2 years of follow-up, the operation produced a significant increase in the range of dorsiflexion of the first metatarsophalangeal joint in these patients, reaching near-normal values. Preoperative and postoperative measurements, using a pressure-distribution measurement system, show that peak pressure beneath the hallux and the first metatarsal head remained unchanged. However, peak pressure was significantly increased beneath the second metatarsal head and decreased beneath the fifth metatarsal head. These findings suggest that the foot functioned in a less inverted manner postoperatively. Compared with normal feet, hallux limitus feet demonstrated significantly higher peak pressure beneath the fourth metatarsal head preoperatively and postoperatively.