Behcet’s disease (Silk Road disease): a rare inflammatory disease

Background: Behcet’s disease (Silk Road disease), a rare immune-mediated multisystem inflammatory disorder described by intermittent oralaphthae and genital ulcer, backsliding uveitis, mucocutaneous, articular, gastrointestinal, neurological and vascular manifestations, with no cure.It is brought about by changes in the: a) arteries that flexibly blood to the body tissues b) veins that return the blood to the lungs, the rear of the eyes retina, brain, joints, skin and bowels. Case Presentation: A 55-year-old male patient was sensed with c/o joint agony in lower appendages, oral ulcer and scrotal ulcer. On physical assessment the patient was cognizant and oriented with B/L lower leg joint emanation. All lab examination including RA factor was within normal limits, with diminished Serum Vitamin D. HLA B51, ANA were checked and oral mucosal biopsy was done. The most punctual sign exhibited was oral disintegration, various shallow ulcer and scarcely any dissolved knobs in the scrotum. At that point the patient gave joint pain and numbness on right leg. On neurological assessment, a strange motor nerve conduction saw with right tibial neuropathy. At first, doubt with syphilis and tarsal tunnel disorder and following 7-8 days of affirmation, analyzed as Behcet's illness dependent on dermatological, rheumatologic and neurological signs. Treatment given was symptomatic and supportive with pain relievers, corticosteroid, antibiotics, IV fluids, PPI, vitamin supplement, laxative and local anaesthetic. Discussion:Without adequate data it's difficult to examine, in light of anomaly and standardized treatment are questionable at present. New information with respect to its immunopathogenesis, genetics will significantly help in the advancement of research center tests, diagnostic criteria and particularly in the decision of the best treatment

An Erratic Origin of Quadratus Plantae: An Embryological Error

Background: Quadratus plantae (Flexor digitorum accessorius) is one of the plantar muscles of foot . It is present in the second layer of sole. It takes origin from calcaneus and gets inserted into the tendon of flexor digitorum longus. The main function of it is to flex the lateral four toes in any position of the ankle joint by pulling on tendons of the flexor digitorum longus. Its variations like high origin have been implicated in the causation of tarsal tunnel syndrome. Methodology and Results: In routine dissection done on 22 cadavers, we observed a bilateral variant muscle flexor digitorum accessorius longus on both right and left sides in a male cadaver. The modality of choice in diagnosing the accessory muscle is magnetic resonance imaging. Conclusion: The knowledge of this variation would be essential to anatomists, radiologists and also to the foot surgeons while performing posterior ankle endoscopy. KEY WORDS: Flexor digitorum Accessorius longus, Tarsal tunnel syndrome, Posterior ankle endoscopy.

Assessment of the frequency of tarsal tunnel syndrome in rheumatoid arthritis

Objectives: In this study, we aimed to determine the frequency of tarsal tunnel syndrome (TTS) in rheumatoid arthritis (RA) patients. Patients and methods: Thirty RA patients (1 male, 29 females; mean age: 41.9±10.1 years; range, 26 to 65 years) who met the American College Rheumatology (ACR) classification criteria and 20 healthy volunteers (1 male, 19 females; mean age: 39.3±10.8 years; range, 26 to 60 years) without any complaints between August 2006 and October 2007 were included in the study. Demographic characteristics of the study group were assessed and neurological examinations were performed. The Tinel’s sign was checked to provoke the TTS symptoms. Disease severity was measured using Visual Analog Scale (VAS), Disease Activity Score-28 (DAS28), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). The health-related quality of life and disability status were determined using the Health Assessment Questionnaire (HAQ), Short Form 36 (SF-36), Foot Function Index (FFI), and VAS (0-100 mm). The positional relationship of the foot pain was questioned with VAS. The 100-m walking distance of the patient and control groups were calculated. Results: Bilateral TTS was detected in 10 of the patients (33.3%) with rheumatoid arthritis. No relationship with the TTS disease duration, seropositivity, rheumatoid nodule, joint deformities, corticosteroid use, and DAS28 score were found. In correlation with TTS, foot and ankle joint were the first involved joints at the beginning of RA disease (p<0.005). The Tinel’s sign was found to be 45% positive in patients with TTS. The 100-m walking time was significantly longer in RA patients compared to the control group (p<0.0001). Conclusion: Tarsal tunnel syndrome is commonly seen in RA and its incidence increases in patients with primary foot involvement. Therefore, caution should be taken against the entrapment neuropathies in these patients, and they should be supported by electrophysiological practices, when the diagnosis is necessary.

Tarsal tunnel syndrome: current rationale, indications and results

Tarsal tunnel syndrome (TTS) is a neuropathy due to compression of the posterior tibial nerve and its branches. It is usually underdiagnosed and its aetiology is very diverse. In 20% of cases it is idiopathic. There is no test that diagnoses it with certainty. The diagnosis is usually made by correlating clinical history, imaging tests, nerve conduction studies (NCSs) and electromyography (EMG). A differential diagnosis should be made with plantar fasciitis, lumbosacral radiculopathy (especially S1 radiculopathy), rheumatologic diseases, metatarsal stress fractures and Morton’s neuroma. Conservative management usually gives good results. It includes activity modification, administration of pain relief drugs, physical and rehabilitation medicine, and corticosteroid injections into the tarsal tunnel (to reduce oedema). Abnormally slow nerve conduction through the posterior tibial nerve usually predicts failure of conservative treatment. Indications for surgical treatment are failure of conservative treatment and clear identification of the cause of the entrapment. In these circumstances, the results are usually satisfactory. Surgical success rates vary from 44% to 96%. Surgical treatment involves releasing the flexor retinaculum from its proximal attachment near the medial malleolus down to the sustentaculum tali. Ultrasound-guided tarsal tunnel release is possible. A positive Tinel’s sign before surgery is a strong predictor of surgical relief after decompression. Surgical treatment achieves the best results in young patients, those with a clear aetiology, a positive Tinel’s sign prior to surgery, a short history of symptoms, an early diagnosis and no previous ankle pathology. Cite this article: EFORT Open Rev 2021;6:1140-1147. DOI: 10.1302/2058-5241.6.210031

Vasculitic Tibial Mononeuropathy Associated with Inherited Immune Dysregulation: A Review of Tibial Mononeuropathies with Electrodiagnostic Considerations

Compressive tibial mononeuropathies are uncommon and can be caused by conditions including posterior compartment syndrome, soleal sling syndrome, and tarsal tunnel syndrome. Therefore, it is critical to consider noncompressive etiologies when a tibial mononeuropathy is suspected. This is a patient with a history of rare inherited immune dysregulation that presented to the electrodiagnostic laboratory with severe neuropathic pain in the right foot associated with plantarflexion weakness, concerning for a tibial mononeuropathy. However, the patient’s clinical presentation and results on electrodiagnostic testing were not consistent with any of the above entities. Therefore, noncompressive etiologies of tibial mononeuropathies such as vasculitis had to be considered. The patient subsequently underwent sural nerve biopsy which confirmed small-vessel vasculitis as the cause of the tibial mononeuropathy. She was then started on appropriate immunosuppressive treatment which resulted in significant pain relief and was discharged home. This case highlights the importance of considering noncompressive causes of tibial nerve injury. Compressive and vasculitic tibial mononeuropathies along with their electrodiagnostic considerations are reviewed. Furthermore, this case highlights the critical role of the electromyographer and ability to maximize the impact on patient care through a solid foundation in anatomy, pathophysiology, and electrodiagnosis blended with clinical acumen.

Biomechanical Response of the Human Foot Model Exposed to Vibrations: A Finite Element Analysis

Prolonged exposure to mechanical vibration has been associated with many musculoskeletal, vascular and sensorineural disorders of the foot from simple Plantar fasciitis and Achilles Tendonitis to complex ones as Tarsal tunnel syndrome (TTS) and Vibration white feet/toes. Foot-transmitted vibrations (FTV) are exposed to the occupants using vibrating equipment’s or standing on vibrating platforms. Prolonged exposure to foot-transmitted vibrations (FTV) can lead to syndromes like vibration white feet/toes may result in tingling sensation, blanching of the toes and even numbness in the feet and toes. A multi-layered two dimensional, plane strain finite element model is developed from the actual cross-section of the human foot to study the stresses and strains developed in the skin and soft tissues. The foot is assumed to be in contact with a steel plate, mimicking the interaction between the foot and the work platform. The skin and the subcutaneous tissue are considered as hyperelastic and viscoelastic. The effects of loading in the form of displacements and the frequency of sinusoidal vibration on a time-dependent stress/strain distribution at various depths in the subcutaneous tissue of the foot are investigated. The simulations indicate that lower frequency vibrations penetrate deep into the subcutaneous tissue while higher frequencies are concentrated in the outer skin layer. The present biomechanical model may serve as a valuable tool to study the response of foot of those who work on a vibrating platform.