Purpose

Tarsal Tunnel Syndrome (TTS) was first reported by Keck and Lam separately in 1962. It has been regarded as the lower limb equivalent to Carpal Tunnel Syndrome (CTS). The gold standard of diagnosis proposed over the years is nerve conduction study (NCS). In reality, TTS is much harder to diagnose and treat compared to CTS. Signs and symptoms can be mimicked by other foot and ankle conditions. Our unit had not seen a single positive nerve conduction result of TTS in clinically suspicious cases. We have therefore audited our 10 year experience.

Following ankle sprain, there can be many causes of disability including ligament injuries, soft tissue or bony impingement, Peroneal tendon tears, osteochondral defects (OCD), synovitis and Osteoarthritis (OA)

Aim: To assess the use of Ankle MRI in clinical decision-making in patients with pain and/or chronic instability following ankle sprains.

Method: A retrospective case note review was undertaken for all ankle scopes performed and all Ankle MRI ordered by a single surgeon (AOA) over a three-year period (April 2004 – April 2007).

Results: During this period 54 Ankle arthroscopies were performed. 24 had pre op MRI scans (16 ordered by AOA and 8 by others who then referred the patient) and 30 had no MRI. 8 case notes were not available.

In 43 of the 46 available notes the patients presented with either chronic ankle pain or instability following ankle sprain. 32 had Anterolateral soft tissue impingement on arthroscopy. Of these 24 had MRI scans with only 3 reporting a soft tissue impingement.

13 patients had lateral ligament reconstruction. All 13 of these patients showed signs of instability on examination under anaesthesia (EUA). Of these 9 had MRI scans with 4 reporting a ligamentous injury. Five other patients had MRI scans that showed a lateral ligament injury but had a normal EUA and did not undergo a ligament reconstruction.

10 patients had moderate to severe OA on arthroscopy of the ankle. Of these 4 had MRI scans with 2 reporting OA changes but 2 reported as OCD.

Conclusion: Analysing the available data suggests that the indication to perform an arthroscopy is not dependent on the results of the MRI scan but is a clinical one.

The decision to reconstruct/repair the lateral ligament complex is a clinical one dependent on patient symptom and the EUA findings.

Aim: Our aim was to measure plantar foot pressures in normal individuals and to compare them with variations in patients with metatarsalgia.

Methodology: We measured the plantar foot pressures in different parts of the foot in normal subjects of various ages and then compared this with foot pressures of patients with metatarsalgia. For measurement and statistical analysis, the plantar contact of the foot was divided into six anatomical divisions. The foot pressures were measured under the hallux, head of first metatarsal, over heads of second, third and fourth metatarsals, the fifth metatarsal, midfoot and hindfoot. This was measured using the FSCAN insole pedobarograph system (Tekscan, Inc, Boston, MA).

The foot pressures were measured in Kilopascals(Kpa). Independent T-tests was used to compare mean pressure distributions in the six anatomical divisions. We found the mean pressures through the 5th metatarsal head – 217(t=−2.32,p< 0.05) and midfoot 94(t=−3.17, p< 0.05), were significantly higher when compared to pressures in normal subjects (table 1).

Conclusion: We have demonstrated increased pressures transmitted through the outer aspect of the sole of the foot, in patients suffering from metatarsalgia. This can be used further to plan any foot- orthosis or surgery to distribute pressures more evenly across the sole of the foot.

Introduction Plantar foot pressure measurements using pressure distribution instruments is a standard tool for diagnostic and therapeutic interventions. Foot pressure studies have measured pressure distributions in patients with various conditions such as rheumatoid arthritis, diabetes and obesity . Pressure studies in metatarsalgia and Hallux rigidus, to our knowledge, has not been reported previously. Our aim was to measure plantar foot pressures in normal individuals and to compare them with variations in patients with metatarsalgia and Hallux rigidus. This data may enable us to identify areas of abnormal pressure distributions and thus plan foot-orthosis or surgical intervention.

Materials and Methods This was a case control study. We measured the plantar foot pressures in different parts of the foot in normal subjects of various ages and then compared this with foot pressures of patients with metatarsalgia and hallux rigidus. For measurement and statistical analysis, the plantar contact of the foot was divided into six anatomical divisions. The foot pressures were measured under the hallux, head of first metatarsal, over heads of second, third and fourth metatarsals, the fifth metatarsal, midfoot and hindfoot. This was measured using the FSCAN insole pedobarograph system (Tekscan, Inc, Boston, MA).

Results The foot pressures were measured in Kilopascals(Kpa). Independent T-tests was used to compare mean pressure distributions in the six anatomical divisions. Comparing normal with metatarsalgia, the mean pressures through the 5th metatarsal head 217(t=−2.32,p< 0.05) and midfoot 94(t=−3.17, p< 0.05), were significantly higher when compared to pressures in normal subjects. In patients with hallux rigidus, the mean pressures through the hallux 314 (t=−3.62, p< 0.01) and mid-foot 140 (t=-5.11, p< 0.01), were significantly higher, as compared to pressures in normal subjects.

Discussion Metatarsalgia is a condition that presents with pain under the region of the 2nd to 4th metatarsal heads. Hence, the normal response of the body would be to avoid putting increased pressure through this region, thus causing increased pressures to be transmitted through other parts of the foot. The foot pressures through the hallux and midfoot were higher in patients with hallux rigidus (compared to normal). This results in pressure imbalances and thus may contribute to pain, deformity and abnormal gait. Our study, confirms this, the mean plantar foot pressures were higher under the 5th metatarsal head and the midsole as compared to normal subjects. This could be explained by the tendency to walk on the outer aspect of the sole to avoid the painful area. Thus, any foot orthosis or surgery should aim to redistribute these forces.

Conclusion We have demonstrated increased pressures transmitted through the outer aspect of the sole of the foot, in patients suffering from metatarsalgia. The pressures through the Hallux and midfoot were higher in oatients with hallux rigidus. This information can be used further to plan any foot-orthosis or surgery to distribute pressures more evenly across the sole of the foot.

Objective: Our aim was the record variation in foot pressures through parts of the foot, in normal subjects and compare with foot pressure distribution in patients with conditions of the foot such as symptomatic hallux rigidus and metatarsalgia.

Methodology: This was an observational study. We assessed the foot pressure distributions in 30 normal subjects, using the foot pressure pedobarograph system. The foot pressures were measured through the Hallux, 1st Metatarsal head, 2,3,4th metatarsal heads, 5 metatarsal head, midfoot and hindfoot. Foot pressure in patients with hallux rigidus and metatarsalgia were compared with the pressures in normal subjects, using statistical analysis.

Results: The foot pressures were measured in Kilopascals(Kpa). Independent T test was used to compare pressures. In patients with hallux rigidus, the mean pressures through the hallux 314 (t= −3.62, p< 0.01) and midfoot 140 (t=−5.11, p< 0.01), were significantly higher, as compared to pressures in normal subjects. In patients with metatarsalgia, the mean pressures through the 5th metatarsal head 217 (t=−2.32, p< 0.05) and midfoot 94 (t=−3.17, p< 0.01), was significantly higher when compared to pressures in normal subjects.

Conclusion: The foot pressures through the hallux and midfoot were higher in patients with hallux rigidus (compared to normal). Thus any foot orthosis or surgery should aim to relieve the pressure through these regions. Whereas, foot pressures through 5th metatarsal head and midfoot were higher in patients with metatarsalgia (compared to normal). This reflects the adaptation the foot develops to avoid the painful region and thus any orthosis or surgery should try to spread the foot pressures evenly across the foot.

Eighty-two consecutive patients with forefoot pain and clinical signs strongly suggesting a neuroma all underwent ultrasound scan of both feet using a 10-5 MHz transducer where a well defined hypoechoic area defined a neuroma . All ultrasound positive feet had the lump excised surgically for histological studies. Plain x-rays were done on all symptomatic feet to exclude other pathology.

Sixty-four feet had an ultrasound positive diagnosis. Of these, there were 82.3% female and 17.1% male (ratio 4.8:1 , p< 0.001). Thirty-six percent had bilateral neuromata but with only one side being symptomatic.59.5% of the neuroma were located in the interspace between the third and fourth toes whilst 41.5% were found in the interspace between the second and third toes.

The size of the lesions varied from 3 to 11mm with a mean of 6.86mm. No lesion less than 5mm was symptomatic in our series.

One false positive was noted in the series giving the test a sensitivity of 97.9% but the specificity was low at 50% as the scan negative feet were not surgically explored for ethical reasons

All surgically explored patients had become asymptomatic at an average of 5.3 weeks (range 4–24 weeks) post surgery. Thirty-three ultrasound negative patients treated non-operatively were completely asymptomatic at an average of 30 weeks (range 6–50 weeks).

We conclude that an ultrasound scan is a cheap, non-invasive, time-efficient test useful in identifying interdigital neuroma as a cause of forefoot pain.