Lessons learnt from an aggressive tumour masquerading as a neuropathic heel ulcer: a case report.

Cutaneous malignant melanoma (cMM) can develop at any site, but one-third of cases primarily affect the lower extremities, with ankle and foot lesions representing 3-15% of all cases. However, cMM may become a clinical conundrum when it presents as chronic ulceration that is clinically indiscernible from other lower extremity ulcers in patients with diabetes. We present the case of a 71-year-old female patient with a longstanding history of diabetes, hypertension, obesity, chronic kidney disease and heart failure who presented to our hospital with a fungating heel ulcer. The lesion was initially managed in another hospital as a neuropathic diabetic foot ulcer (DFU), treated by multiple local wound debridement. However, the ulcer progressed into a fungating heel lesion that interfered with the patient's mobility and quality of life. Consequently, the patient was referred to our specialist diabetic foot service for further management. Excisional biopsy of the lesion disclosed a cMM. Positron emission tomography/computed-tomography scanning revealed hypermetabolic ipsilateral inguinal lymphadenopathy, and a right cerebral metastasis for which palliative chemotherapy was initiated. Immunotherapy was considered, but the patient died before it was started. Atypical foot ulcers in patients with diabetes warrant a careful diagnostic approach, especially for recalcitrant cutaneous lesions not responding to standard therapies. Conscientious management, without undue delay in obtaining a histopathological diagnosis, might lead to early diagnosis of melanoma and potentially more favourable outcomes. This case highlights the importance of consideration of atypical foot lesions, in general practice in addition to referral centres, to try to identify alarming features and act accordingly.

Fixation with multiple K-wires and PRP injection as an effective way to manage heel pad avulsion.

The treatment of acute heel pad avulsion differs significantly from managing other soft tissue injuries due to its unique soft tissue structure. This case report outlines a scenario involving a male in his 20s who suffered heel pad avulsion without a calcaneal fracture but with an ipsilateral medial malleolus fracture after a twisting injury to the ankle caused by a road traffic accident. Immediate action was taken within 24 hours of the injury, involving thorough debridement of the wound, fixation to the calcaneum using multiple K-wires, primary suturing and internal fixation of the medial malleolus with two cannulated cancellous screws. Postoperative care included PRP (platelet-rich plasma) injections into the wound twice, removal of K-wires after 6 weeks and allowing walking with full weight bearing after 8 weeks. A year later, the wound had completely healed, and the patient was comfortably walking pain-free with full weight-bearing capabilities.

Application of Human Acellular Dermal Matrix with Skin Graft for Lacunar Soft-Tissue Defect of Lateral Heel after Calcaneal Fracture.

OBJECTIVE: To investigate the clinical effect of human acellular dermal matrix (HADM) combined with split-thickness skin graft in repairing lacunar soft tissue defects of the lateral heel after calcaneal fracture. METHODS: From June 2018 to October 2020, providers repaired 11 cases of lacunar soft tissue defects at the lateral part of the heel using HADM combined with split-thickness skin graft. After thorough debridement, the HADM was trimmed and filled into the lacunar defect area. Once the wound was covered, a split-thickness skin graft and negative-pressure wound therapy were applied. Providers evaluated the appearance, scar, ductility of the skin graft site, appearance of the donor site, healing time, and any reoperation at follow-up. RESULTS: Of the 11 cases, 8 patients achieved successful wound healing by primary intention. Three patients showed partial necrosis in the edge of the skin graft, but the wound healed after standard wound care. Evaluation at 6 and 12 months after surgery showed that all patients had wound healing and mild local scarring; there was no obvious pigmentation or scar formation in the donor skin area. The average healing time was 37.5 days (range, 24-43 days). CONCLUSIONS: The HADM combined with split-thickness skin graft is a simple and effective reconstruction method for lacunar soft tissue defect of the lateral heel after calcaneal fracture. In this small sample, the combination demonstrated few infections, minor scar formation, few donor site complications, and relatively short hospital stays.

Efficacy of heel lifts for mid-portion Achilles tendinopathy (the LIFT trial): study protocol for a randomised controlled trial.

BACKGROUND: Mid-portion Achilles tendinopathy is a common condition, characterised by localised Achilles tendon load-related pain and dysfunction. Numerous non-surgical treatments have been proposed for the treatment of this condition, but many of these treatments have a poor or non-existent evidence base. Heel lifts have also been advocated as a treatment for Achilles tendinopathy, but the efficacy and mechanism of action of this intervention is unclear. This proposal describes a randomised controlled trial comparing the effectiveness of heel lifts versus sham heel lifts for reducing pain associated with mid-portion Achilles tendinopathy, with an embedded biomechanical analysis. METHODS: One hundred and eight men and women aged 18 to 65 years with mid-portion Achilles tendinopathy (who satisfy the inclusion and exclusion criteria) will be recruited. Participants will be randomised, using the website Sealed Envelope, to either a control group (sham heel lifts) or an experimental group (heel lifts). Both groups will be provided with education regarding acceptable pain levels to ensure all participants receive some form of treatment. The participants will be instructed to use their allocated intervention for at least 8 h every day for 12 weeks. The primary outcome measure will be pain intensity (numerical rating scale) at its worst over the previous week. The secondary outcome measures will be additional measures of Achilles tendon pain and disability, participant-perceived global ratings of change, function, level of physical activity and health-related quality of life. Data will be collected at baseline and the primary endpoint (week 12). Data will be analysed using the intention-to-treat principle. In addition, the acute kinetic and kinematic effects of the interventions will be examined at baseline in a subpopulation of the participants (n = 40) while walking and running using three-dimensional motion analysis. DISCUSSION: The LIFT trial (efficacy of heeL lIfts For mid-portion Achilles Tendinopathy) will be the first randomised trial to compare the efficacy of heel lifts to a sham intervention in reducing pain and disability in people with Achilles tendinopathy. The biomechanical analysis will provide useful insights into the mechanism of action of heel lifts. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN12623000627651 . Registered 7 June 2023.

Transient pain and discomfort when wearing high-heeled shoes.

In the dynamic world of fashion, high-heeled footwear is revered as a symbol of style, luxury and sophistication. Yet, beneath the facade of elegance of classy footwear lies the harsh reality of discomfort and pain. Thus, this study aims to investigate the influence of wearing high-heeled shoes on the sensation of pain across different body regions over a period of 6 h. It involved fifty female participants, all habitual wearers of high-heeled shoes, aged between 20 and 30 years. Each participant kept a record of their perceptions of pain and discomfort every hour for a total of 6 h using a 0-10 pain scale with 0 indicating no pain and 10 indicating severe pain. The findings reveal a progressive rise in pain throughout wear, with the most intense pain reported in the back, calcaneus, and metatarsals. The analysis shows that after approximately 3.5 h, participants experience significant increases in pain levels. However, the relationship between heel height and pain is not linear. It appears that a heel height of 7.5 cm is the threshold where overall body pain becomes significant. The study suggests that a duration of 3.5 h of wear and a heel height of 7.5 cm serve as critical points to decrease overall body pain. Moreover, beyond this heel height, knee pain diminishes compared to other body areas possibly due to the shift towards a more neutral posture. The study findings, coupled with the recommendations, can assist footwear designers in crafting not only stylish but also comfortable shoes.

The effect of maternal voice and non-nutritional sucking on repeated procedural pain of heel prick in neonates: a quasi-experimental study.

BACKGROUND: Neonates in the neonatal intensive care unit undergo frequent painful procedures. It is essential to reduce pain using safe and feasible methods. PURPOSE: To evaluate the effects of non-nutritional sucking, mother's voice, or non-nutritional sucking combined with mother's voice on repeated procedural pain in hospitalized neonates. METHODS: A quasi-experimental study was conducted in which 141 neonates were selected in a hospital in Changsha, China. Newborns were divided into four groups: non-nutritional sucking (NNS) (n = 35), maternal voice (MV) (n = 35), NNS + MV (n = 34), and control (n = 37) groups. The Preterm Infant Pain Profile-Revised Scale (PIPP-R) was used to assess pain. RESULTS: During the heel prick, the heart rate value and blood oxygen saturation were significantly different between the groups (P < 0.05). Both non-nutritional sucking and maternal voice significantly reduced PIPP-R pain scores of hospitalized newborns (P < 0.05). The pain-relief effect was more robust in the combined group than in other groups. CONCLUSIONS: This study showed that both non-nutritional sucking and the mother's voice alleviated repeated procedural pain in neonates. Therefore, these interventions can be used as alternatives to reduce repeated procedural pain.

A realist evaluation of devices used for the prevention of heel pressure ulcers: An ethnographic study of clinical practice.

BACKGROUND: It is known that heel offloading devices are widely used in clinical practice for the prevention of heel pressure ulcers, even though there is a lack of robust, good quality evidence to inform their use. OBJECTIVE: To explore how and why heel offloading devices are used (or not used) and reasoning behind their use in population at high risk of developing heel pressure ulcers. METHODS: An ethnographic study was conducted as part of a realist evaluation in three orthopaedic wards in a large English hospital. Twelve observations took place, with 49 h and 35 min of patient care observed. A total of 32 patients were observed and 19 members of the nursing team were interviewed and in-depth interviews with the three ward managers were conducted. RESULTS: Although the focus of the study was on offloading devices, constant low pressure heel specific devices were also observed in use for pressure ulcer prevention, whilst offloading devices were perceived to be for higher risk patients or those already with a heel pressure ulcer. Nursing staff viewed leadership from the ward manager and the influence of the Tissue Viability Nurse Specialists as key mechanisms for the proactive use of devices. CONCLUSIONS: This study informs trial design as it has identified that a controlled clinical trial of both types of heel specific devices is required to inform evidence-based practice. Involving the ward managers and Tissue Viability Nurse Specialists during set up phase for clinical equipoise could improve recruitment. Tweetable abstract How, for whom, and in what circumstances do devices work to prevent heel pressure ulcers? Observations of clinical practice.

The frictional energy absorber effectiveness and its impact on the pressure ulcer prevention performance of multilayer dressings.

Pressure ulcers including heel ulcers remain a global healthcare concern. This study comprehensively evaluates the biomechanical effectiveness of the market-popular ALLEVYN® LIFE multilayer dressing in preventing heel ulcers. It focuses on the contribution of the frictional sliding occurring between the non-bonded, fully independent layers of this dressing type when the dressing is protecting the body from friction and shear. The layer-on-layer sliding phenomenon, which this dressing design enables, named here the frictional energy absorber effectiveness (FEAE), absorbs approximately 30%-45% of the mechanical energy resulting from the foot weight, friction and shear acting to distort soft tissues in a supine position, thereby reducing the risk of heel ulcers. Introducing the novel theoretical FEAE formulation, new laboratory methods to quantify the FEAE and a review of relevant clinical studies, this research underlines the importance of the FEAE in protecting the heels of at-risk patients. The work builds on a decade of research published by our group in analysing and evaluating dressing designs for pressure ulcer prevention and will be useful for clinicians, manufacturers, regulators and reimbursing bodies in assessing the effectiveness of dressings indicated or considered for prophylactic use.

Modeling foot rockers via functional calibration for use in clinical gait analysis.

BACKGROUND: Goal of this work is a quantitative description of Jacquelin Perry's rocker concept by locating the position of the heel rocker and the forefoot rocker within segments of the foot via functional calibration. METHODS: Two functional calibration tasks with the foot in ground contact were performed by ten typical developed adults and foot marker motion was captured. After applying a least-square method for constructing foot segments, their motion relative to the floor was analyzed via a functional algorithm. Resulting reference positions - namely the heel rotation center and the metatarsal rotation axis - were calculated. Further, the repeatability of the method and variability of outcome within the cohort was tested. RESULTS: The heel rotation center is located substantially posterior (25 mm) and slightly more inferior (5 mm). to the midpoint of the two markers placed medially and laterally on the calcaneus. Repeated measures reveal a variation of this location around 5 mm. The forefoot center is slightly more medial to the "toe marker" (DMT2) and substantially more inferior (19 mm). The metatarsal rotation axis is slightly tilted in the frontal and transverse plane against the metatarsal line given between markers on MT1 and MT5 with small variation in repeated measures (1-2°). SIGNIFICANCE: The determination of heel rotation center and the metatarsal rotation axis relative to foot segments can be determined with good repeatability and their location meet the intuitive expectation. Since they have a direct biomechanical meaning in the foot roll-over process in gait, they may be used for a more functionally oriented definition of foot segments potentially improving the calculation of foot kinematics and kinetics in future work.

Coverage of defects over Posterior aspect of Ankle Joint and Heel with Lateral Calcaneal Artery Flap- Experience in Mymensingh Medical College Hospital.

Lateral calcaneal artery flap is randomly used by many Plastic Surgeons for covering any defect on the posterior aspect of heel. A prospective observational study was conducted in the Department of Burn and Plastic Surgery, Mymensingh Medical College Hospital, Mymensingh, Bangladesh from January 2020 to June 2022, to see the outcome of the flap for coverage of defects over the posterior aspect of ankle joint and heel. A total number of 09 patients, selected by purposive sampling, were included in the study. The age of the patients ranged from 06 years to 70 years. The cause of the defects were post traumatic in 07 cases, electric burn in 01 case and pressure sore in 01 case. The defect sizes varied from 3×2 to 6×3cm. and flap size ranged from 4×2.5 to 7×4.5cm. The follow-up period ranged from 3 to 6 months. All the flaps survived completely without any complications; except in two cases. In one case, there was marginal epidermal necrolysis that healed secondarily without the need of any further surgical intervention. In the other case, there was gangrene of about 0.5 cm area at the flap tip, which was debrided and the resulting wound healed secondarily. The average operating time was 63 minutes. The results were satisfactory on the context of adequate coverage, and flap and donor site morbidity. So, the lateral calcaneal artery flap can be a good and safe option for the coverage of posterior ankle and heel defects.

Ultrasonography in plantar fibromatosis: the conduit between heel pain and 'catwalk'.

.

The Heel Complex: Anatomy, Imaging, Pathologic Conditions, and Treatment.

The differential diagnosis for heel pain is broad but primarily involves abnormalities of the Achilles tendon, calcaneus, and plantar fascia. Achilles tendon disorders include tendinosis, tendinitis, and partial or complete tears. Tendinosis refers to tendon degeneration, while tendinitis is inflammation after acute overload. Untreated tendinosis can progress to partial or complete tears. Tendon disorders can be accompanied by paratenonitis or inflammation of the loose sheath enclosing the tendon. Initial management involves rehabilitation and image-guided procedures. Operative management is reserved for tendon tears and includes direct repair, tendon transfer, and graft reconstruction. The calcaneus is the most commonly fractured tarsal bone. The majority of fractures are intra-articular; extra-articular fractures, stress or insufficiency fractures, medial process avulsion, and neuropathic avulsion can also occur. Posterosuperior calcaneal exostosis or Haglund deformity, retrocalcaneal bursitis, and insertional Achilles tendinosis form the characteristic triad of Haglund syndrome. It is initially managed with orthotics and physiotherapy. Operative management aims to correct osseous or soft-tissue derangements. The plantar fascia is a strong fibrous tissue that invests the sole of the foot and contributes to midfoot stability. Inflammation or plantar fasciitis is the most common cause of heel pain and can be related to overuse or mechanical causes. Acute rupture is less common but can occur in preexisting plantar fasciitis. Conservative treatment includes footwear modification, calf stretches, and percutaneous procedures. The main operative treatment is plantar fasciotomy. Plantar fibromatosis is a benign fibroblastic proliferation within the fascia that can be locally aggressive and is prone to recurrence. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Acute effects of negative heel shoes on perceived pain and knee biomechanical characteristics of runners with patellofemoral pain.

BACKGROUND: To determine the effects of negative heel shoes on perceived pain and knee biomechanical characteristics of runners with patellofemoral pain (PFP) during running. METHODS: Sixteen runners with PFP ran in negative (-11 mm drops) and positive (5 mm drops) heel shoes while visual analog scale (VAS) scores, retroreflective markers, and ground reaction force were acquired by applying a 10-cm VAS, infrared motion capture system, and a three-dimensional force plate. Knee moment, patellofemoral joint stress (PFJS), and other biomechanical parameters during the stance phase were calculated based on inverse dynamics and a biomechanical model of the patellofemoral joint. RESULTS: The foot inclination angle, peak PFJS during the stance phase, patellofemoral joint reaction force, knee extension moment, and quadriceps force at the time of peak PFJS of runners with PFP in negative heel shoes were lower than that in positive heel shoes, no significant difference was found in VAS scores, knee flexion angle, patellofemoral contact area, and quadriceps moment arm at the time of peak PFJS. CONCLUSIONS: Compared to positive heel shoes, running in negative heel shoes decreases peak PFJS in runners with PFP, which may decrease patellofemoral joint loading, thus reducing the possibility of further development of PFP. TRAIL REGISTRATION: Sports Science Experiment Ethics Committee of Beijing Sport University. 2023095H, April 18, 2023 (prospectively registered).

"Antero-medial load shift" in unilateral plantar heel pain - A cross-sectional exploratory study.

BACKGROUND AND PURPOSE: Plantar foot pressure provides an insightful data in the ankle and foot complex which may aid in the detection of underlying pathology. Since individuals with unilateral plantar heel pain (PHP) tend to develop compensatory loading strategies, this study aimed to observe the foot loading pattern compared to the asymptomatic side and its relationship with the morphological variations in individuals with unilateral PHP. METHODS: It was a prospective cross-sectional study done on 17 participants with unilateral PHP. The calcaneal inclination and calcaneal first metatarsal angles were measured using lateral weight-bearing radiographs for both symptomatic and asymptomatic feet. Static and dynamic plantar foot pressures for both sides were obtained using a "Portable baropodometry platform 0, 5 m Entry Level footscan®. RESULTS: On the symptomatic side, the pressure in the lateral heel was reduced by 65% in static and 67% in dynamic measurements, while in the medial heel, it was reduced by 16 % in static and 47 % in dynamic measurements compared to that of the asymptomatic side. There was a transfer of pressure from the hind foot to the forefoot by 44 % in static and 46 % in dynamic measurements resulting in anterior load shift. It was also observed that the prevalence of PHP was higher in the normal arched foot (59%). CONCLUSION: Based on the observations, compared to the asymptomatic side, patients with unilateral plantar heel pain exhibited an anteromedial load shift (AMLS) in their plantar pressures. PHP was reported higher in the foot with normal morphology. LEVEL OF EVIDENCE: Level 4.

Heel skin microclimate control: Secondary analysis of a self-controlled randomized clinical trial.

OBJECTIVE: this study was undertaken to evaluate the efficacy of multilayer polyurethane foam with silicone (MPF) compared to transparent polyurethane film (TPF) dressings in the control of heel skin microclimate (temperature and moisture) of hospitalized patients undergoing elective surgeries. METHOD: the study took of a secondary analysis of a randomized self-controlled trial, involving patients undergoing elective surgical procedure of cardiac and gastrointestinal specialties in a university hospital in southern Brazil, from March 2019 to February 2020. Patients served as their own control, with their heels randomly allocated to either TPF (control) or MPF (intervention). Skin temperature was measured using a digital infrared thermometer; and moisture determined through capacitance, at the beginning and end of surgery. The study was registered in the Brazilian Registry of Clinical Trials: RBR-5GKNG5. RESULTS: significant difference in the microclimate variables were observed when the groups (intervention and control) and the timepoint of measurement (beginning and end of surgery) were compared. When assessing temperature, an increase (+3.3 °C) was observed with TPF and a decrease (-7.4 °C) was recorded with MPF. Regarding skin moisture, an increase in moisture (+14.6 AU) was recorded with TPF and a slight decrease (-0.3 AU) with MPF. CONCLUSIONS: The findings of this study suggest that MPF is more effective than TPF in controlling skin microclimate (temperature and moisture) in heels skin of hospitalized patients undergoing elective surgeries. However, this control should be better investigated in other studies.

Effect of sensor location for modifying center of pressure during gait using haptic feedback in people with chronic ankle instability.

BACKGROUND: Gait retraining using haptic biofeedback medially shifts the center of pressure (COP) while walking in orthopedic populations. However, the ideal sensor location needed to effectively shift COP medially has not been identified in people with chronic ankle instability (CAI). RESEARCH QUESTIONS: Can a heel sensor location feasibly be employed in people with CAI without negatively altering kinematics? Does a heel sensor placement relative to the 5th metatarsal head (5MH) impact COP location while walking in people with CAI? METHODS: In this exploratory crossover study, 10 participants with CAI walked on a treadmill with vibration feedback for 10 minutes with a plantar pressure sensor under the heel and 5MH. Separate 2×2 repeated measures analyses of covariances (rmANCOVAs) were used to compare the averaged COP location and 3-D lower extremity kinematics from the first 10% of stance before and after training and between sensor locations. Baseline measures served as covariates to adjust for baseline differences. RESULTS: Feedback triggered by a heel sensor resulted in 40% of participants avoiding a heel strike. There were no significant main effects or interactions between time and sensor location on COP location when controlling for baseline COP (p>0.05). However, with the 5MH placement, participants displayed less ankle internal rotation(IR) (5MH/Heel: -4.12±0.00º/ -6.43±0.62º), less forefoot abduction (-4.29±0.00º/ -5.14±1.01º), more knee flexion (3.40±0.32º/ 0.14±0.57º), less knee external rotation (-10.95±0.00º/-11.24±1.48º), less hip extension (-0.20±0.00º/-1.42±1.05º), and less hip external rotation (3.12±0.00º/3.75±1.98º). SIGNIFICANCE: A 5MH location may be more feasible based on difficulties maintaining heel strike when the sensor was under the heel. While no sensor location was statistically better at changing the COP, the 5MH location decreased proximal transverse plane motions making participants' gait more like controls. Individual response variations support comprehensive lower extremity assessments and the need to identify responder profiles using sensory feedback in people with CAI.

Modularity Implications of an Overground Exoskeleton on Plantar Pressures, Strength, and Spasticity in Persons with Acquired Brain Injury.

This study explored the effects of a modular overground exoskeleton on plantar pressure distribution in healthy individuals and individuals with Acquired Brain Injury (ABI). The research involved 21 participants, including ABI patients and healthy controls, who used a unique exoskeleton with adaptable modular configurations. The primary objective was to assess how these configurations, along with factors such as muscle strength and spasticity, influenced plantar pressure distribution. The results revealed significant differences in plantar pressures among participants, strongly influenced by the exoskeleton's modularity. Notably, significant distinctions were found between ABI patients and healthy individuals. Configurations with two modules led to increased pressure in the heel and central metatarsus regions, whereas configurations with four modules exhibited higher pressures in the metatarsus and hallux regions. Future research should focus on refining and customizing rehabilitation technologies to meet the diverse needs of ABI patients, enhancing their potential for functional recovery.

Evaluation of the efficacy of trigger points combined with extracorporeal shock waves in the treatment of plantar fasciitis: heel temperature and plantar pressure.

BACKGROUND: Plantar fasciitis (PF) is the most common cause of heel pain. Among conservative treatments, extracorporeal shock wave therapy (ESWT) is considered effective for refractory PF. Studies have shown that applying ESWT to the trigger points (TrPs) in the triceps surae may play an important role in pain treatment in patients with PF. Therefore, the purpose of this study was to combine the concept of trigger points and ESWT to explore the effect of this combination on plantar temperature and pressure in patients with PF. METHODS: After applying inclusion and exclusion criteria, 86 patients with PF were recruited from the pain clinic of Huadong Hospital, Fudan University and randomly divided into experimental (n = 43) and control groups (n = 43). The experimental group was treated with extracorporeal shock waves to treat the medial heel pain point and the gastrocnemius and soleus TrPs. The control group was only treated with extracorporeal shock waves at the medial heel pain point. The two groups were treated twice with an interval of 1 week. Primary measurements included a numerical rating scale (NRS) score (overall, first step, heel pain during daily activities), and secondary measurements included heel temperature, Roles-Maudsley score (RMS), and plantar pressure. All assessments were performed before treatment (i.e., baseline) and 6 and 12 weeks after treatment. RESULTS: During the trial, 3 patients in the experimental group withdrew from the study, 2 due to interruption of the course of treatment by the COVID-19 epidemic and 1 due to personal reasons. In the control group, 3 patients fell and were removed due to swelling of the heel. Therefore, only 80 patients with PF were finally included. After treatment, the two groups showed good results in NRS score (overall, first step, heel pain during daily activities), RMS, and plantar temperature, especially in the experimental group, who showed a significantly better effect than the control group. CONCLUSION: ESWT of the heel combined with the triceps trigger point of the calf can more effectively improve the pain, function and quality of life of refractory PF than ESWT of the heel alone. In addition, ESWT of the heel combined with the triceps trigger point of the calf can effectively reduce the skin temperature of the heel on the symptomatic side, indicating that the heel temperature as measured by infrared thermal imaging may be used as an independent tool to evaluate the therapeutic effect for patients with chronic PF. Although extracorporeal shock waves combined with TrPs treatment can cause changes in the patients' gait structure, plantar pressure is still difficult to use as an independent tool to evaluate the therapeutic effect for PF. TRIAL REGISTRATION: Registered in the Chinese Clinical Trial Registry ( www.chictr.org.cn ) on 12/17/2021 with the following code: ChiCTR-INR-2,100,054,439.

A complicated Chiari type 1 malformation and holocord syrinx as a likely cause for heel pain.

BACKGROUND: Chiari malformations are a rare group of rhomboencephalic abnormalities involving the brain, craniocervical junction and spine. They may manifest in a variety of clinical presentations which relate to the variable involvement of the cerebellum, brainstem, lower cranial nerves, spinal cord and altered CSF flow dynamics. METHOD: We report an unusual case of incidental diagnosis of a type I Chiari malformation with secondary cystic cerebellar tonsillar encephalomalacia and holocord syrinx following investigation of a 5YO girl presenting with heel swelling related to progressive neuropathic osteoarthropathy of the posterior calcaneal body and apophysis. RESULT: The child was treated with decompressive suboccipital craniectomy and C1 laminectomy and tonsillar resection. Cerebellar tonsillar gliosis and cystic degeneration were confirmed on histopathology. Referral for ongoing engagement with occupational and physical therapy. CONCLUSION: Most type I Chiari malformations in the paediatric population are incidental and asymptomatic. Neurological symptoms are typically mild and relate to altered CSF flow dynamics; however, we present a complex case of type I Chiari malformation with an unusual constellation of associated complications.