跟痛症的治疗进展

跟痛症是中老年人的常见病、多发病,由一系列疾病导致的以足跟部疼痛为主症的症候群。常由跖腱膜炎、跟骨骨刺、足跟脂肪垫炎、跟下滑囊炎、足底神经卡压、跟腱炎、跟腱滑囊炎、跟骨高压症、跟骨应力骨折等引起。严重影响患者的工作与生活,故跟痛症的治疗越来越受人们的关注。目前,对跟痛症的治疗方法报道很多,且效果不一,本文就近年来的治疗情况作一综述。     

Is plantar foot sensation associated with standing balance in type 2 diabetes mellitus patients

To examine the relationship between one-leg standing balance (OLSB) and different modalities of foot sole sensation in patients with type 2 diabetes mellitus (T2DM). Forty patients diagnosed with T2DM (mean age, 53.96 ± 15.31 years) and ten healthy control subjects were included. Duration of OLSB was measured with digital chronometer. Threshold of light-touch pressure (LTP), evaluated with full Semmes-Weinstein Monofilament Test Kit, and distance of two-point discrimination (TPD), evaluated with aesthesiometer, were assessed at six different regions of the foot sole. Thresholds of the LTP at all regions were significantly correlated with duration of OLSB (p < 0.05). However, there was no relationship between TPD sensation and duration of OLSB (p > 0.05). LTP at the plantar side of the great toe was the most related area with the OLSB (r = −0.48, p < 0.05). In patients with T2DM, LTP, and TPD sensations of foot sole and duration of OLSB were decreased compared to healthy controls. In this study, there was a moderate correlation between LTP sensation and balance. Other factors that would affect the balance in patients with T2DM should be investigated.

     

Psychosocial variables and presence,severity and prognosis of plantar heel pain: A systematic review of cross‐sectional and prognostic associations

Objective

Plantar heel pain (PHP) is often disabling, and persistent symptoms are common. Psychosocial variables are known to affect pain and disability but the association of these factors with PHP has yet to be established. The purpose of the present systematic review was to determine if psychosocial variables are associated with the presence, severity and prognosis of PHP.

Methods

A systematic review of the literature and qualitative synthesis was carried out. Electronic searches of MEDLINE, CINAHL, SPORTDiscus, PsycINFO and EMBASE were undertaken from the inception of the respective databases up to November 2017. Any study design incorporating measurements of psychosocial variables with participants with plantar heel pain were included. The quality of included articles was appraised using the Newcastle Ottawa Scale.

Results

Five articles from four studies were included in the review, with a total of 422 participants. Moderate‐level evidence suggested a clinically unimportant association with the incidence of PHP and depression, anxiety and stress, and limited evidence suggested a clinically unimportant association with job dissatisfaction. Moderate‐level evidence suggested that there may also be an association between depression, anxiety, stress and catastrophization and PHP pain, and between depression, anxiety, stress, catastrophization and kinesiophobia and PHP function. We also found moderate‐level evidence that a psychological disorder may be associated with a poorer outcome to shockwave therapy.

Conclusion

In light of this review, the association of psychosocial variables and plantar heel pain cannot be ruled out. Given recommendations to adopt an individualized and stratified approach to other musculoskeletal conditions, clinicians should remain vigilant to their presence.     

The relationship of disease duration to foot function, pain and disability in rheumatoid arthritis patients with foot complaints

OBJECTIVE: To assess the relationship between disease duration and foot function (expressed as pressure and gait parameters), foot pain and disability, in patients with foot complaints secondary to rheumatoid arthritis (RA). METHODS: Sixty-two patients with RA-related foot complaints were included. Disease duration was defined as the time since RA was diagnosed. A pressure platform was used to measure both pressure parameters (i.e. pressure-time integrals and peak pressures in the forefoot) and gait parameters (i.e. total loading time and loading time in different foot regions). In addition, measurements of foot pain, disability (i.e. walking time and self reported disability), forefoot joint damage and disease activity were obtained. Data were analysed using partial correlations (Spearman), correcting for age. RESULTS: Disease duration was significantly correlated with the maximum pressure-time integral (PTI) measured under the forefoot (r = 0.330, p = 0.01). Disease duration was also significantly correlated with gait parameters, i.e. total loading time (r = 0.265, p = 0.04), duration of heel loading and duration of toe loading (r = 0.326, p = 0.01 and r = -0.288, p = 0.03 respectively), and walking time (r = 0.297, p = 0.02). Disease duration did not correlate with self-reported foot pain or disability. CONCLUSION: In patients with RA-related foot complaints, longer disease duration is associated with impaired foot function and reduced walking speed. These findings are interpreted as an alteration in pressure distribution and gait pattern during the course of disease, with a shift from a heel-to-toe roll-over process to a more shuffling gait.     

Effectiveness and safety of warm needling therapy combined with electroacupuncture for patients with plantar heel pain syndrome: A protocol for systematic review and meta-analysis

Background:Several studies have reported positive therapeutic effects of electroacupuncture, warm needling, or a combination of the 2 for heel pain; however, the quality of the evidence is limited by methodological limitations. Given that there are no high-quality meta-analyses or reviews incorporating the available evidence, the aim of this study was to systematically review the level I evidence in the literature to determine whether a combination of electroacupuncture and warm needling therapy is more beneficial than acupuncture alone in patients with plantar heel pain syndrome.Methods:From the inception to May 2022, the Wanfang, CNKI, EMBASE, PubMed, Web of Science, and Cochrane Library electronic databases will be searched using the key phrases “acupuncture”, “warm needling”, “electroacupuncture”, “heel pain”, “plantar pain”, and “prospective” for all relevant studies. The outcomes include pain, physical disability, plantar fascia thickness, and foot functional status. Quality assessment of all studies included in this review will be independently assessed by 2 reviewers using the Cochrane Collaborations tool. We consider significant heterogeneity between trials if I² > 50%, and severe heterogeneity if I² > 75%. When significant heterogeneity is indicated, we will find the source of heterogeneity by subgroup or sensitivity analysis.Results:The results of our review will be reported strictly following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines and the recommendations of the Cochrane Collaboration.Conclusions:We initially hypothesized that combination therapy would lead to better treatment outcomes.Registration number: 10.17605/OSF.IO/VWBYJ.     

A systematic review of instruments measuring foot function, foot pain, and foot-related disability in patients with rheumatoid arthritis

OBJECTIVE: To compose an inventory of instruments that have been described to measure foot function (i.e., pressure and/or gait parameters), foot pain, and foot-related disability in rheumatoid arthritis (RA), and to investigate the clinimetric quality of these measures. METHODS: A systematic search was conducted in Medline, CINAHL, EMBase, and Sportdiscus. Standardized criteria, extended with levels of evidence, were applied to assess the quality of the clinimetric studies and the properties (i.e., reliability, validity, and responsiveness) of the described instruments. RESULTS: A variety of measurement instruments were identified. Only 16 instruments have been studied for their measurement properties in RA patients: 7 for assessing foot function, 3 for measuring foot-related disability, and 6 for measuring both foot pain and foot-related disability. Thirteen instruments were rated for reliability, of which 10 were rated positively on different levels of evidence. No positive rating for absolute measurement error was applicable for any of the tests. Internal consistency was reported for 7 instruments; 3 assigned a positive rating. For 2 instruments, Rasch analysis was used to assess the methodologic quality. A positive rating was reported for goodness-of-fit only, not for item calibration. Seven instruments were rated for construct validity, and 3 assigned a positive rating. Only 2 instruments were rated positively for responsiveness. CONCLUSION: This review offers a basis for choosing the most appropriate instruments for measuring foot function, foot pain, and foot-related disability in RA patients, both for clinical practice and for research. Further research on the quality of these measures is urgently needed.     

A systematic review of instruments measuring foot function,foot pain,and foot‐related disability in patients with rheumatoid arthritis

Objective

To compose an inventory of instruments that have been described to measure foot function (i.e., pressure and/or gait parameters), foot pain, and foot‐related disability in rheumatoid arthritis (RA), and to investigate the clinimetric quality of these measures.

Methods

A systematic search was conducted in Medline, CINAHL, EMBase, and Sportdiscus. Standardized criteria, extended with levels of evidence, were applied to assess the quality of the clinimetric studies and the properties (i.e., reliability, validity, and responsiveness) of the described instruments.

Results

A variety of measurement instruments were identified. Only 16 instruments have been studied for their measurement properties in RA patients: 7 for assessing foot function, 3 for measuring foot‐related disability, and 6 for measuring both foot pain and foot‐related disability. Thirteen instruments were rated for reliability, of which 10 were rated positively on different levels of evidence. No positive rating for absolute measurement error was applicable for any of the tests. Internal consistency was reported for 7 instruments; 3 assigned a positive rating. For 2 instruments, Rasch analysis was used to assess the methodologic quality. A positive rating was reported for goodness‐of‐fit only, not for item calibration. Seven instruments were rated for construct validity, and 3 assigned a positive rating. Only 2 instruments were rated positively for responsiveness.

Conclusion

This review offers a basis for choosing the most appropriate instruments for measuring foot function, foot pain, and foot‐related disability in RA patients, both for clinical practice and for research. Further research on the quality of these measures is urgently needed.     

Randomized trial of custom orthoses and footwear on foot pain and plantar pressure in diabetic peripheral arterial disease

Aim Custom‐made foot orthoses reduce plantar pressure, ulceration and amputation in patients with diabetes mellitus. There is limited evidence of their effect on foot pain. In a randomized, single‐blind, sham‐controlled trial, the efficacy of custom orthoses on foot pain and plantar pressure in diabetic patients with peripheral arterial disease was investigated. Methods Sixty‐one participants were randomly assigned to either custom foot orthoses (n = 30) or sham insoles (n = 31). Both groups also received standardized walking footwear. Outcomes included foot pain and function, mean pressure, toe‐brachial index, average daily steps, disability, comfort, quality of life, adherence and adverse events. A multivariate predictive model was constructed to explore factors contributing to pain relief during the trial. Results At 8 weeks, 95% of participants provided follow‐up data, adherence was high and there were few adverse events. Foot pain and function scores significantly improved at 8 weeks with both custom orthoses and the sham, but there was no significant difference between groups. Custom orthoses reduced pressure significantly more than the sham. There were no significant differences between groups for toe‐brachial index, daily steps, disability, comfort or quality of life. Regression modelling identified inappropriate pre‐trial footwear as the strongest predictor of foot pain relief during the trial. Conclusions Custom foot orthoses significantly reduced plantar pressure compared with the sham, but there were no significant differences between groups for pain or function. The high‐quality walking footwear provided to both groups may explain this finding. Footwear should have greater emphasis as the clinical intervention.     

Extracorporeal shock wave application for chronic plantar fasciitis associated with heel spurs: prediction of outcome by magnetic resonance imaging

OBJECTIVE: To clarify morphologic features associated with the clinical outcome of extracorporeal shock wave application (ESWA) in chronic plantar fasciitis. METHODS: In this prospective study 43 patients (48 heels) with chronic courses of plantar fasciitis were clinically examined before and after repetitive low energy ESWA. Standard radiographs of the affected heels were obtained before ESWA to document the existence of a calcaneal heel spur. Magnetic resonance imaging (MRI) was performed before ESWA to evaluate abnormalities of the plantar fascia, the surrounding soft tissue structures, and bone marrow edema of the calcaneus. RESULTS: After ESWA (mean followup 19.3 mo), clinical evaluation of all 48 heels revealed a statistically significant decrease in the mean visual analog scale score from 74.5 to 25.4. Using the Roles and Maudsley score (RM), an established scoring system for categorizing results of treatment following ESWA for patients with plantar fasciitis, patients could be divided into 2 groups, i.e., satisfactory clinical outcome of ESWA (grades 1 and 2 by RM scale; n = 36 heels) and unsatisfactory outcome (grades 3 and 4 by RM scale; n = 12 heels). While thickness of plantar aponeurosis, soft tissue signal intensity changes, and soft tissue contrast medium uptake did not correlate with clinical outcome, the presence of a calcaneal bone marrow edema was highly predictive for satisfactory clinical outcome (positive predictive value 0.94, sensitivity 0.89, specificity 0.8). CONCLUSION: This study indicates that in patients with chronic plantar fasciitis, the presence of calcaneal bone marrow edema on pretherapeutic MRI is a good predictive variable for a satisfactory clinical outcome of ESWA.     

Downloading plantar foot pressures in the diabetic patient

Pressure downloading (offloading) is the most important component in the prevention and treatment of diabetic foot ulcers because peripheral neuropathy is a major contributing factor to more than 90% of all diabetic foot ulcers. Downloading techniques range from the simplest insole, through many types of orthotics and footwear modifications including the ankle-foot orthosis and total contact casting, to surgical procedures. A philosophical difference exists between surgical and nonsurgical approaches, with the patient subjected to the bias of the practitioner. This article explores uniting both surgical and nonsurgical pressure downloading techniques, using a modified Carville Classification System to help the practitioner determine the appropriate method(s) of downloading. By adding a Category 4 to include diabetic persons with foot ulcers or acute Charcot events, a seamless system is obtained to categorize and treat all people with diabetes with pressure downloading recommendations.     

Determinants of plantar pressures in the diabetic foot

The aim of this study was to determine, by the use of regression analysis, the factors that are associated with the increased plantar pressure in the diabetic foot. In-shoe plantar pressure measurements using the Novel Pedar were carried out on 50 subjects with diabetes. Variables measured were age, body weight, duration of diabetes, a number of selected structural radiographic angles, soft tissue thickness, plantarflexion, and dorsiflexion strength at the ankle and first metatarsophalangeal joint, Neuropathy Symptom Score, and the Michigan Neuropathy Disability Score. Stepwise regression modelling indicates that 28% of the variability in hallux peak pressure could be explained by the first metatarsophalangeal joint range of motion and the Michigan Neuropathy Disability Score (P=.0004). The Michigan Neuropathy Disability Score explained 17% of the peak pressure under the first metatarsal head (P=.002). None of the measured variables could explain any of the variation in peak pressure plantar to the lateral forefoot. Thirty-two percent (32%) of the variability in peak pressure under the heel was explained by the Michigan Neuropathy Disability Score and age (P<.0001). Very little of the variation in the pressure time integrals could be explained by the measured variables except for 10.3% of the variation in the pressure time integral for the heel being explained by body weight. This study has shown that neuropathy-related variables play an important role in the plantar pressure under the diabetic foot. The range of motion of the first metatarsophalangeal joint is also important in determining pressures under the hallux.     

Small‐fibre involvement in diabetic patients with neuropathic foot pain

Aims To assess small‐fibre involvement in diabetic patients with neuropathic pain. Methods Peripheral nerve function was assessed in 30 patients with Type 2 diabetes mellitus (T2DM, n = 24) or impaired glucose tolerance (IGT, n = 6), and clinical symptoms of neuropathic pain in the feet, using nerve conduction studies, autonomic tests, thermal quantitative sensory testing (T‐QST) and quantification of intra‐ and subepidermal nerve fibre densities in skin punch biopsies. Results Clinical signs of isolated small‐fibre sensory involvement were present in 13 patients [pure small‐fibre neuropathy (pSFN)], seven patients had isolated positive sensory symptoms without neurological deficits (pSFN–). Ten patients had concomitant electrophysiological and/or clinical signs of large‐fibre sensory involvement [mixed‐fibre neuropathy (MFN)]. Twenty‐seven patients (90%) had both reduced skin innervation and abnormalities of the T‐QST parameters. Two other patients displayed either abnormal skin innervation or T‐QST, and only one patient had normal findings on both tests. The criteria of small‐fibre neuropathy (SFN) were met in all 20 patients without large‐fibre involvement. Small‐fibre involvement was also present in the 10 MFN patients. Both T‐QST and skin biopsy parameters revealed significant differences between these clinical subgroups, with increased severity of small‐fibre involvement in the MFN group. Autonomic dysfunction was found in 43% of patients and did not correlate with either clinical, T‐QST or skin biopsy data. Conclusions Although the exact mechanism of neuropathic pain in diabetic patients is not known, pain is almost invariably accompanied by small‐fibre dysfunction and pathology irrespective of autonomic or large‐fibre involvement.     

Risk factors associated with diabetic foot ulcer-free survival in patients with diabetes

Aims

This study was done to assess the risk factors associated with diabetic foot ulcer-free survival in patients with diabetes.