Biomechanical consequences of total plantar fasciotomy: a review of the literature.

BACKGROUND: Plantar fascia release for chronic plantar fasciitis has provided excellent pain relief and rapid return to activities with few reported complications. Cadaveric studies have led to the identification of some potential postoperative problems, most commonly weakness of the medial longitudinal arch and pain in the lateral midfoot. METHODS: An electronic search was conducted of the MEDLINE, ScienceDirect, SportDiscus, EMBASE, CINAHL, Cochrane, and AMED databases. The keywords used to search these databases were plantar fasciotomy and medial longitudinal arch. Articles published between 1976 and 2008 were identified. RESULTS: Collectively, results of cadaveric studies suggested that plantar fasciotomy leads to loss of integrity of the medial longitudinal arch and that total plantar fasciotomy is more detrimental to foot structure than is partial fasciotomy. In vivo studies, although limited in number, concluded that although clinical outcomes were satisfactory, medial longitudinal arch height decreased and the center of pressure of the weightbearing foot was excessively medially deviated postoperatively. CONCLUSIONS: Plantar fasciotomy, in particular total plantar fasciotomy, may lead to loss of stability of the medial longitudinal arch and abnormalities in gait, in particular an excessively pronated foot. Further in vivo studies on the long-term biomechanical effects of plantar fasciotomy are required.

An evaluation of the long-term effects of total plantar fasciotomy--a preliminary study.

BACKGROUND: Plantar fascia release for chronic plantar fasciitis has given excellent pain relief and rapid return to activities with few reported complications. Cadaveric studies have led to the identification of some potential post-operative problems, commonly weakness of the medial longitudinal arch (MLA) and pain in the lateral midfoot. METHODS: Eight total plantar fasciotomy patients (five bilateral and three unilateral) were evaluated subjectively and objectively with regards to surgical outcome and biomechanical change. The centre of pressure (COP) and loading of the foot were measured using the F Scan mobile system and COM'nalysis software. In addition, five control subjects were evaluated with the F Scan. The reading for one foot of one of the control subjects was discarded due to a biomechanical abnormality. RESULTS: The results of this study were that the COP of the foot in post-total plantar fasciotomy subjects was significantly laterally deviated throughout the propulsive phase of gait compared to that of control subjects (p<0.05). There was no significant difference in plantar pressure at the rearfoot or the first metatarsophangeal joint (MTPJt) between the post-operative and control groups (p>0.05). Six of the eight of the post-operative patients (11 feet) considered the procedure to be successful in resolving their symptoms. CONCLUSION: Total plantar fasciotomy may result in changes to the COP of the foot. It could be extrapolated from this data, in conjunction with subjective visual clinical observations of gait, that supination of the foot could occur post-operatively rather than the pronatory state secondary to a collapsed arch that, collectively, the results of cadaver studies have suggested. The conclusions drawn from this pilot study are to some extent speculative, as the measurements were only made post-operatively and a small number of subjects were studied. Further research is required in this area.

A prospective randomized controlled study of the role of botulinum toxin in whiplash-associated disorder.

OBJECTIVES: To investigate the effectiveness of botulinum toxin in preventing the development of chronic whiplash-associated disorder. DESIGN: Prospective, randomized, placebo-controlled double-blind study. SETTING: Regional Neurological Rehabilitation Centre with participants being at home. SUBJECTS: Thirty-seven patients with whiplash-associated disorder who remained symptomatic two months after injury. INTERVENTIONS: Patients were randomized to receive either 250 units botulinum toxin type A (Dysport) or placebo (normal saline). Four trigger points were injected with 0.625 mL of injectant. OUTCOME MEASURES: Tenderness to palpation scores, visual analogue pain scale, Vernon-Mior Neck Pain and Disability Index and cervical range of motion. Follow-up assessments were carried out at four weeks and three months after treatment. RESULTS: Twenty participants received botulinum toxin and 17 received placebo. Both groups showed a tendency towards improvement in pain scores, Vernon-Mior Index and range of motion at four weeks and three months, with the changes being more pronounced in the toxin group. The change in Vernon-Mior Index in the toxin group was both statistically and clinically significant (i.e. a change of score of > or = 5 from baseline to follow-up). Group comparisons did not meet statistical significance. CONCLUSION: The improvements in outcome measures suggest that botulinum toxin type A may have a role to play in the management of whiplash-associated disorder but larger studies are required to clarify the situation.

Etiologic factors in the development of medial tibial stress syndrome: a review of the literature.

BACKGROUND: Medial tibial stress syndrome is a type of exercise-induced leg pain that is common in recreational and competitive athletes. Although various studies have attempted to find the exact pathogenesis of this common condition, it remains unknown. METHODS: Various theories in literature from 1976 to 2006 were reviewed using key words. RESULTS: Until recently, inflammation of the periosteum due to excessive traction was thought to be the most likely cause of medial tibial stress syndrome. This periostitis has been hypothesized by some authors to be caused by the tearing away of the muscle fibers at the muscle-bone interface, although there are several suggestions as to which, if any, muscle is responsible. CONCLUSIONS: Recent studies have supported the view that medial tibial stress syndrome is not an inflammatory process of the periosteum but instead a stress reaction of bone that has become painful.

Is eccentric muscle contraction a significant factor in the development of chronic anterior compartment syndrome? A review of the literature.

INTRODUCTION: The purpose of this article was to review published articles investigating the association of eccentric contractions of the anterior compartment with an increase in intramuscular pressure. METHODS: An electronic review using Medline, Amed and Science Direct returned 49 papers, seven of which were considered suitable. Manually browsing reference lists of these led to the identification of a further five relevant papers. A further nine papers were considered as suitable for background reading. RESULTS: Results of previous studies have indicated that there is a relationship between excessive eccentric contractions, delayed onset of muscle soreness, and an increase in intramuscular pressure. However, due to the differences in a number of variables between these studies a direct comparison cannot be made. CONCLUSION: Eccentric contractions of the anterior compartment have, in the short term, been associated with an increase in intra-compartmental pressure and delayed onset of muscle soreness in studies on healthy volunteers. There is no evidence as yet that there is a further association with the development of chronic anterior compartment syndrome. The long term effect of excessive eccentric contraction is believed to be a reduction of compliance in and loss of elasticity of the fascia, which is probably irreversible.

Lessons learned from the implementation of clinical messaging systems.

The Regenstrief Institute has designed and implemented two clinical messaging systems over the past six years, both called DOCS4DOCS. These systems receive HL7 messages from data sources and deliver results to clinicians via the web, fax, or as HL7 directed to an EMR. This paper focuses on some of the lessons we have learned, both good and bad. We discuss important issues in clinical messaging including provider mapping, document delivery and duplicate prevention, creating uniform HL7 outbound feeds, user authentication, the problems of allowing Active-X controls, why automatic printing of documents is not important although a frequently requested feature, and assorted other pearls of wisdom we have acquired.

Indianapolis I3: the third generation Integrated Advanced Information Management Systems.

In 2001, the Regenstrief Institute for Health Care and the Indiana University School of Medicine (IUSM) began an IAIMS planning effort to create a vision and a tactical plan for the first Integrated Advanced Information Management Systems (IAIMS) implementation to cross a large area and include unaffiliated institutions. A number of elements made this planning effort unique. Among these elements were the existence of a network infrastructure that supported the Indianapolis Network for Patient Care, the existence of a mature medical informatics program at the Regenstrief Institute, and the existence of a wide-area knowledge network fostered by the IUSM libraries. However, the leadership for a strong information technology role in the IUSM that could promote collaboration in support of education and research across the diverse Indianapolis hospital systems had been lacking. By bringing together various groups, each with a commitment to improve health care quality and public health across the Indianapolis metropolitan area, regardless of individual institutional affiliation, the strategic directions for I3-Indianapolis IAIMS Initiative have been defined and the foundations for a third generation IAIMS construct have been laid in Indianapolis, Indiana.

A review of the management of Guillain-Barré syndrome in a regional neurological rehabilitation unit.

A database search was performed to identify all patients presenting to a Rehabilitation Centre over a five-year period with a confirmed diagnosis of Guillain-Barré syndrome. Retrospective analysis of acute and rehabilitation hospital notes was performed and information on demographics, management and outcome obtained. There were equal numbers of males and females with an average age of 36 years. 75% had a prodromal illness and 62.5% presented with distal paraesthesia. 75% exhibited cranial nerve signs and 62.5% required artificial ventilation for a prolonged period. The investigations performed and treatment given varied and did not always coincide with current evidence. An aetiological agent was identified in 50%. There were a wide variety of complications in the acute hospital and the inpatient stay was prolonged in all but 1. There was one complication after transfer to the rehabilitation unit and statistical analysis of the admission and discharge FIM scores revealed a statistically significant improvement in outcome (p = 0.013). There is currently no consensus on the management of patients with GBS in the acute setting despite a wide evidence base. Many patients are being discharged without access to rehabilitation services. Our results suggest that rehabilitation makes a measurable and significant difference and should be available to all patients with GBS.

Outcome of surgical treatment of medial tibial stress syndrome.

BACKGROUND: Medial tibial stress syndrome is a common chronic sports injury characterized by exercise-induced pain along the posteromedial border of the tibia. The reported outcomes of surgical treatment of this condition have varied. METHODS: Of seventy-eight patients who underwent surgery for medial tibial stress syndrome, forty-six (thirty-one men and fifteen women) returned for follow-up. The outcomes of the surgery were determined by comparing preoperative and postoperative pain levels as indicated on a visual analog pain scale and ascertaining the ability of the athletes to return to presymptom levels of exercise. RESULTS: The mean duration of postoperative follow-up was thirty months (range, six to sixty-three months). Surgery significantly reduced pain levels (p < 0.001) by an average of 72% as indicated on the visual analog pain scale. An excellent result was achieved in 35% of the limbs; a good result, in 34%; a fair result, in 22%; and a poor result, in 9%. Despite the success with regard to pain reduction, for a variety of reasons only nineteen (41%) of the athletes fully returned to their presymptom sports activity. CONCLUSIONS: Surgery can significantly reduce the pain associated with medial tibial stress syndrome. Despite this reduction in pain, athletes should be counseled that a full uninhibited return to sports is not always achieved.