Ultrasound findings in subcutaneous plantar vein thrombosis: retrospective analysis of seven patients

Background Several disorders may result in forefoot pain. An uncommon cause of forefoot pain is subcutaneous plantar veins thrombosis (SCPVT) involving veins superficial to the plantar fascia. Purpose To describe the ultrasound (US) appearance of SCPVT, which has been described only once in the radiological literature. Material and Methods We performed a retrospective search of our PACS system from 2016 to 2020 to collect all cases of US-diagnosed SCPVT. We collected data on seven patients. Two radiologists analyzed the US images retrieved. All US examinations were performed with a multifrequency linear probe (frequencies in the range of 5–17 MHz). Results A localized plantar nodule was palpable in 86% of patients. The subcutaneous thrombosed vein appeared in all patients as a round or ovoid nodule located in the subcutaneous tissues that corresponded in four patients (4/5, 80%) to the painful palpable nodule. The size was in the range of 4–7 mm (mean = 5.4 mm). The thrombosed vein presented a connection with adjacent patent veins, appeared enlarged, and almost filled with hypo-isoechoic material, and in two patients (2/7, 29%), a thin peripheral fluid component surrounding the thrombus was detectable. Continuous scanning demonstrated slow blood movements inside the peripheral component due to blood circulation. Failure to compress the lumen of the thrombosed vein during the real-time US was evident in all patients. Conclusion SCPVT is a rare or underreported condition. Sonologists must know the US appearance of SCPVT to exclude other conditions and avoid unnecessary invasive studies.

A Predictive Model for Gastrocnemius Tightness in Forefoot Pain and Intractable Plantar Keratosis of the Second Rocker

Background Many people experience gastrocnemius tightness. Few studies demonstrate the relationship between gastrocnemius tightness and forefoot pathology. This study aimed to define the association between intractable plantar keratosis of the second rocker (IPK2) (also known as well-localized IPK or discrete keratosis) and metatarsalgia. Methods The Silfverskiöld (ST) and lunge (LT) tests, used for measuring ankle dorsiflexion, were applied to diagnose gastrocnemius tightness. An instrument for measuring accurate performance and the force to be applied (1.7–2.0 kg of force to the ankle dorsiflexion) complemented the ST for clinical diagnosis and to obtain repeatedly reliable results (the authors apply force manually, which is difficult to quantify accurately). Results Of 122 patients studied, 74 were used to devise a prediction model from a logistic regression analysis that determines the probability of presenting gastrocnemius tightness in each test (LT and ST) with the following variables: metatarsalgia, IPK2, and maximum static pressure (baropodometry). The IPK2 plays the principal role in predicting this pathology, with the highest Wald values (6.611 for LT and 5.063 for ST). Metatarsalgia induces a somewhat lower change (66.7% LT and 64.3% ST). The maximum pressure of the forefoot is equally significant (P = .043 LT and P = .025 ST), taking α < .05 as the significance level. Conclusions The results of this validation report confirm that a model composed of metatarsalgia, IPK2, and maximum pressure in static acts as a predictive method for gastrocnemius tightness.

Conservative Treatment for Primary Metatarsalgia

Metatarsalgia is one of the most common causes of forefoot pain, and it is characterized by pain in the front part of the foot under the head of the metatarsal bones. Primary metatarsalgia is idiopathic, but it has been suggested to be related to forefoot plantar compression. Because of the various causes of metatarsalgia, there is the need to thoroughly consider the etiology of metatarsalgia to find novel, effective, and conservative treatments for metatarsalgia to avoid surgical treatment. Pressure reduction or redistribution can be achieved using toe exercise, flat shoe inserts, metatarsal pads, custom-molded inserts, and rockerbars. There was no need for one treatment. If toe function was poor, toe exercises were recommended. If dorsiflexion of the ankle joint was limited, the Achilles tendon was stretched. If the pain was localized to the plantar aspect of the 2nd MTP, a decompression insole was applied. If the pain was limited to the plantar aspect of the 2nd MTP, a decompression insole was worn. If swelling occurred, anti-inflammatory drugs were indicated to reduce inflammation. The combination of the two was appropriate for this condition. Toe exercises can improve balance and are worth trying. An in-depth understanding of the various etiologies of metatarsal and toe deformities is essential for successful treatment.

Plantar forefoot pain: ultrasound findings before and after treatment with custom-made foot orthoses

Purpose No prior studies investigated the role of ultrasound in the assessment of response of patients undergoing treatment of metatarsalgia with custom-made orthoses. Our aim was to describe ultrasound findings of patients with plantar forefoot pain treated with custom-made foot orthoses. Methods Twenty patients (15 females; mean age: 62.6 ± 11 years) affected by metatarsalgia in 27/40 feet underwent clinical evaluation before, three months and six months after treatment with custom-made full foot insole with a support proximal and an excavation below the painful metatarsals. Ultrasound was performed before and three months after the use of orthoses to examine the presence of intermetatarsal/submetatarsal bursitis, metatarsophalangeal joints effusion, anterior plantar fat pad oedema, flexor tendinitis/tenosynovitis, and Morton’s neuroma. Outcome measures were clinical response with Foot Function Index (FFI)/Visual Analogue Scale (VAS) and ultrasound features changes. Results Median VAS and FFI before treatment were 8[5–8.5] and 45.85[32.4–59.4], respectively. After 3 and 6 months of insoles use, both median VAS (2.5 [0–5] and 0 [0–2.75], respectively) and median FFI (7.9 [3.95–20] and 0 [0–3.95], respectively) showed a significant reduction in pain and disability (p < .001). Before treatment, ultrasound revealed 22 intermetatarsal bursitis, 16 submetatarsal bursitis, 10 joint effusions, 20 fat pad oedema, 3 flexor tendinitis/tenosynovitis and 3 Morton’s neuromas. After 3 months of treatment, a significant decrease of intermetatarsal bursitis (7, p < .001) was observed. No significant changes were observed in any other ultrasound parameters. Conclusion Ultrasound might be able to detect some imaging features associated with the response of forefoot pain to custom-made foot orthoses, especially intermetatarsal bursitis.

Level of Excision Matters in Morton Neuroma Surgery.

Introduction: Morton’s neuroma (MN) is mechanical neuropathy of plantar interdigital nerve. It is one of the most common causes of forefoot pain. One of the most undesirable complications of MN surgery is recurrent neuroma. Excision level of MN is important to prevent recurrence. In this study, we aimed to figure out preferred excision levels of orthopedic surgeons by evaluating pathological samples. Methods: 192 samples sent with the diagnosis of Morton neuroma to the pathology department of our hospital between years 2010-2017 were added to our study. Mean age was 45,8 (between 23 to 73). All of 192 patients were primary diagnosed 22 of them was left foot and the other 170 were right foot was. 139 of them were female, and 53 were male. Recurrent neuromas, pathological sample more than one piece from one surgical site were excluded from the study. Results: 192 pathological specimens were prepared and examined by the same pathologist. Gross pathological appearance and histopathology findings were recorded. Mean sample length was 2,05 cm (between 0,8cm and 6 cm).145 samples was smaller (75.5%) than 3cm and only 47 sample (24.5%) was bigger than 3 cm.Conclusion: In conclusion our database results showed that majority of surgeons didn't take into account plantarly directed nerve branches.