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Peroneal neuropathy is a common mononeuropathy of the lower limb. Some studies have reported cases of peroneal neuropathy after vascular surgery or intervention. However, no cases of peroneal neuropathy with occlusion of a single peripheral artery have been previously reported. A 73-year-old man was referred with a 3-week history of left-sided foot drop. He had a history of valvular heart disease and arrhythmia, and had previously been treated with percutaneous coronary intervention. Computed tomography angiogram of the lower extremity showed proximal occlusion of the left anterior tibial artery. An electrodiagnostic study confirmed left common peroneal neuropathy. After diagnosis, anticoagulation therapy was started and he received physical therapy.
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To identify the anatomical motor points of the abductor hallucis muscle in cadavers.
Motor nerve branches to the abductor hallucis muscles were examined in eight Korean cadaver feet. The motor point was defined as the site where the intramuscular nerve penetrates the muscle belly. The reference line connects the metatarsal base of the hallux (H) to the medial tubercle of the calcaneus (C). The x coordinate was the horizontal distance from the motor point to the point where the perpendicular line from the navicular tuberosity crossed the reference line. The y coordinate was the perpendicular distance from the motor point to the navicular tuberosity.
Most of the medial plantar nerves to the abductor hallucis muscles divide into multiple branches before entering the muscles. One, two, and three motor branches were observed in 37.5%, 37.5%, and 25% of the feet, respectively. The ratios of the main motor point from the H with respect to the H-C line were: main motor point, 68.79%±5.69%; second motor point, 73.45%±3.25%. The mean x coordinate value from the main motor point was 0.65±0.49 cm. The mean value of the y coordinate was 1.43±0.35 cm. All of the motor points of the abductor hallucis were consistently found inferior and posterior to the navicular tuberosity.
This study identified accurate locations of anatomical motor points of the abductor hallucis muscle by means of cadaveric dissection, which can be helpful for electrophysiological studies in order to correctly diagnose the various neuropathies associated with tibial nerve components.
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To develop and test the validity and reliability of a new instrument for measuring the thigh-foot angle (TFA) for the patients with in-toeing and out-toeing gait.
The new instrument (Thigh-Foot Supporter [TFS]) was developed by measuring the TFA during regular examination of the tibial torsional status. The study included 40 children who presented with in-toeing and out-toeing gaits. We took a picture of each case to measure photographic-TFA (P-TFA) in the proper position and to establish a criterion. Study participants were examined by three independent physicians (A, B, and C) who had one, three and ten years of experience in the field, respectively. Each examiner conducted a separate classical physical examination (CPE) of every participant using a gait goniometer followed by a TFA assessment of each pediatric patient with or without the TFS. Thirty minutes later, repeated in the same way was measured.
Less experienced examiner A showed significant differences between the TFA values depending on whether TFS used (left p=0.003 and right p=0.008). However, experienced examiners B and C did not show significant differences. Using TFS, less experienced examiner A showed a high validity and all examiner's inter-test and the inter-personal reliabilities increased.
TFS may increase validity and reliability in measuring tibial torsion in patients who has a rotational problem in lower extremities. It would be more useful in less experienced examiners.
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Popliteal entrapment syndrome caused by isolated popliteus muscle enlargement is very rare, although its occurrence has been reported after discrete trauma. However, popliteal artery stenosis with combined peroneal and proximal tibial neuropathy caused by popliteus muscle enlargement without preceding trauma has not been reported. A 57-year-old man presented with a tingling sensation and pain in his left calf. He had no previous history of an injury. The symptoms were similar to those of lumbosacral radiculopathy. Calf pain became worse despite treatment, and the inability to flex his toes progressed. Computed tomography angiography and magnetic resonance imaging of the lower extremity showed popliteal artery stenosis caused by popliteus muscle enlargement and surrounding edema. An electrodiagnostic study confirmed combined peroneal and proximal tibial neuropathy at the popliteal fossa. Urgent surgical decompression was performed because of the progressive neurologic deficit and increasing neuropathic pain. The calf pain disappeared immediately after surgery, and he was discharged after the neurologic functions improved.
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To compare the accuracy rates of non-guided vs. ultrasound-guided needle placement in four lower limb muscles (tibialis posterior, peroneus longus, and short and long heads of the biceps femoris).
Two electromyographers examined the four muscles in each of eight lower limbs from four fresh frozen cadavers. Each electromyographer injected an assigned dye into each targeted muscle in a lower limb twice (once without guidance, another under ultrasound guidance). Therefore, four injections were done in each muscle of one lower limb. All injections were performed by two electromyographers using 18 gauge 1.5 inch or 24 gauge 2.4 inch needles to place 0.5 mL of colored acryl solution into the target muscles. The third person was blinded to the injection technique and dissected the lower limbs and determined injection accuracy.
A 71.9% accuracy rate was achieved by blind needle placement vs. 96.9% accuracy with ultrasound-guided needle placement (p=0.001). Blind needle placement accuracy ranged from 50% to 93.8%.
Ultrasound guidance produced superior accuracy compared with that of blind needle placement in most muscles. Clinicians should consider ultrasound guidance to optimize needle placement in these muscles, particularly the tibialis posterior.
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To demonstrate the bifurcation pattern of the tibial nerve and its branches.
Eleven legs of seven fresh cadavers were dissected. The reference line for the bifurcation point of tibial nerve branches was an imaginary horizontal line passing the tip of the medial malleolus. The distances between the reference line and the bifurcation points were measured. The bifurcation branching patterns were categorized as type I, the pattern in which the medial calcaneal nerve (MCN) branched most proximally; type II, the pattern in which the three branches occurred at the same point; and type III, in which MCN branched most distally.
There were seven cases (64%) of type I, three cases (27%) of type III, and one case (9%) of type II. The median MCN branching point was 0.2 cm (range, -1 to 3 cm). The median bifurcation points of the lateral plantar nerves and inferior calcaneal nerves was -0.6 cm (range, -1.5 to 1 cm) and -2.5 cm (range, -3.5 to -1 cm), respectively.
MCN originated from the tibial nerve in most cases, and plantar nerves were bifurcated below the medial malleolus. In all cases, inferior calcaneal nerves originated from the lateral plantar nerve. These anatomical findings could be useful for performing procedures, such as nerve block or electrophysiologic studies.
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To evaluate the therapeutic effect of a Tibia Counter Rotator (TCR) with toe-out gait plate (GP) upon tibial internal torsion by a comparative analysis of transmalleolar angle (TMA) and gait analysis with GP alone.
Twenty participants with tibial internal torsion were recruited for this study. Each 10 participants were included in group A with TCR and GP application and in group B with GP application only. The TMA and the kinematic results were used for the evaluation of the therapeutic effects of orthoses.
Within each group, TMA showed a significant increase after treatment. Group A showed a continuous improvement up to six months, however, group B showed an improvement up to five months only. Group A showed a significantly higher correction effect than group B after treatment. Regarding kinematic data, both groups showed a significantly decreased mean ankle adduction angle after treatment. However, group A showed a significantly lower mean ankle adduction angle than group B after six months.
The group with TCR and GP showed a significantly better outcome and continued correction force compared to the group with GP only. Our results suggest that TCR with GP may be useful therapeutic orthoses for children with tibial internal torsion.
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Baker cyst is an enlargement of the gastrocnemius-semimembranosus bursa. Neuropathy can occur due to either direct compression from the cyst itself or indirectly after cyst rupture. We report a unique case of a 49-year-old man with left sole pain and paresthesia who was diagnosed with posterior tibial neuropathy at the lower calf area, which was found to be caused by a ruptured Baker cyst. The patient's symptoms resembled those of lumbosacral radiculopathy and tarsal tunnel syndrome. Posterior tibial neuropathy from direct pressure of ruptured Baker cyst at the calf level has not been previously reported. Ruptured Baker cyst with resultant compression of the posterior tibial nerve at the lower leg should be included in the differential diagnosis of patients who complain of calf and sole pain. Electrodiagnostic examination and imaging studies such as ultrasonography or magnetic resonance imaging should be considered in the differential diagnosis of isolated paresthesia of the lower leg.
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Protein S is a vitamin K-dependent coagulation factor that acts as an anticoagulant. Deficiency of protein S increases the risk of thromboembolic events. We report a case of isolated protein S deficiency in a 39-year-old woman suffering arterial occlusion in both lower legs. She underwent a surgical procedure using thrombectomy and balloon angioplasty of her left lower extremity. Later, she had right trans-tibial amputation because of the reperfusion injury. Throughout the evaluation of thromboembolic events, we diagnosed a large thrombus in the right atrium and an asymptomatic pulmonary thromboembolism. The patient was successfully treated with right atrial thrombectomy and systemic anticoagulation. Careful evaluation for protein S levels may be necessary in patients with arterial thromboembolic events, especially young adults.
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To investigate the injury mechanism in patients who had peroneal neuropathy after a tibio-fibular fracture and the correlation between tibio-fibular fracture location and the severity of the peroneal neuropathy by using electrodiagnosis.
Thirty-four patients with peroneal neuropathy after a tibio-fibular fracture were recruited for this study. Their medical records, radiologic and electrodiagnostic findings were investigated retrospectively. They were divided into 2 groups according to the existence of a fibular head fracture. The group of patients without the fibular head fracture was further classified according to the criteria of Orthopedic Trauma Association (OTA) classification. The differences between the two groups in the severity of the neuropathy and electrodiagnostic findings were evaluated.
Nine cases (26.5%) had tibio-fibular fractures with a coexisting fibular-head fracture and 25 cases (73.5%) had tibio-fibular fractures without fractures in the fibular-head area. There was no statistical significance in the correlation between the existence of the fibular head fracture and the severity of the electrodiagnostic findings. Neither was there any statistically significant relationship between the site of the tibio-fibular fracture and the severity of the peroneal neuropathy (p>0.05).
This study showed there were numerous cases with common peroneal neuropathy after tibiofibular fracture without a coexisting fibular-head fracture, which shows the importance of indirect nerve injury mechanisms as well as that of direct nerve injury as a cause of peroneal neuropathy. In addition, this study showed that there was no statistically significant correlation between the site of tibio-fibular fracture and the severity of peroneal neuropathy.
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To evaluate the validity of physical examinations by assessment of correlation between physical examinations and CT measurements in children with intoeing gait and the causes of intoeing gait by age using CT measurements.
Twenty-six children with intoeing gait participated in this study. The internal and external hip rotation, thigh-foot angle and transmalleolar angle were measured. In addition, femoral anteversion and tibial torsion of the subjects were assessed using a CT scan. The measurements of torsional angles were performed twice by two raters. The correlation coefficients between physical examinations and CT measurements were calculated using Pearson correlation. The data was analyzed statistically using SPSS v12.0.
The correlation coefficients between physical examinations and CT measurements were not high. Before 5 years of age, intoeing gait was caused by femoral anteversion in 17.86%, tibial torsion in 32.29% and the combination of causes in 35.71% of cases. After 6 years of age, the contributions changed to 29.17%, 8.33% and 45.83%, respectively.
Before 5 years of age, the common cause of an intoeing gait was tibial torsion, whereas after 6 years of age it was femoral anteversion. Regardless of age, the most common cause of intoeing gait was a combination of causes. This study shows poor correlation between physical examinations and CT. Therefore, it is limiting to use physical examination only for evaluating the cause of intoeing gait in clinical practice.
Citations
Method: The subjects were 37 patients and 30 normal controls. The patient group was composed of 28 patients with L5 radiculopathy and 9 patients with S1 radiculopathy, which were confirmed by clinical, radiological, and electrodiagnostic studies. Tibialis anterior H-reflex (TA-H reflex) was recorded from maximally contracting tibialis anterior muscle by averaging technique and submaximal stimulation of common peroneal nerve. Sensitivities and specificities were delineated from the several diagnostic criteria.
Results: In the normal controls, mean side to side difference in the TA-H reflex latency was 0.66⁑0.48 msec and mean amplitude ratio was 75⁑16%. The diagnostic criteria of abnormal TA-H reflex were latency difference above 1.62 msec and amplitude ratio less than 42.2%. The abnormal TA-H reflexes were shown in 17 out of 28 patients with L5 radiculopathy and 1 out of 9 patients with S1 radiculopathy. Sensitivity and specificity of TA-H reflex as a diagnostic criteria of L5 radiculopathy were 61% and 89%, respectively.
Conclusion: Tibialis anterior H-reflex might be useful in the diagnosis of L5 radiculopathy.
Objective: The aims of this study were to evaluate gait patterns in transtibial amputees with the barefeet relative to the shoe and also to identify the differences between their gait patterns of two different types of prosthetic feet.
Method: An optoelectronic motion analysis of gait was done in six transtibial amputees using both the SACH foot and the single axis foot. In both cases we compared the state of the barefeet with the shod.
Results: The gait abnormalities which were observed during the barefeet gait with the SACH foot showed knee joint hyperextension of 9.9±2.0o and the loss of ankle plantar flexion at the early stance phase. When the single axis foot was used, there was a reduction in knee flexion thrust from 9.9±3.7o to 7.2±3.8o and also in plantar flexion from 9.9±2.8o to 7.0±2.1o during the early stance phase.
Conclusion: There were significant gait abnormalities during the barefoot walking state in transtibial amputees with the SACH foot. We observed that gait patterns have been improved when the single axis prosthetic foot was used.
Innervation anomalies are well-known sources of erroneous interpretation in motor nerve conduction studies. The extensor digitorum brevis (EDB) muscle is supplied by the deep peroneal nerve and is commonly used as recording point in peroneal motor conduction study. If the compound muscle action potentials (CMAPs) are not evoked with EDB muscle recording without any symptoms or signs of peroneal neuropathy, we should lead one to consider either technical pitfall or anomalous innervation. We experienced an anomalous innervation in a woman in whom the bilateral EDB muscles were innervated exclusively by the tibial nerve. This was proved using a monopolar needle electrode for recording in extensor digitorum brevis (EDB) and flexor digitorum brevis (FDB) muscles, which encoded acceptable shape of CMAPs on tibial nerve stimulation. To avoid erroneous interpretation of electromyographic and nerve con
Objective: The purposes of this study were to evaluate the causes of intoeing gait and to investigate the association between femoral anteversion and tibial torsion.
Methods: The subjects were 23 children with intoeing gait. The association between increased femoral anteversion and external torsion of the tibia was investigated by computed tomography and 3-dimensional computed tomography. The tibial torsion angle was measured by computed tomography. Femoral anteversion angle was measured by computed tomography and 3-dimensional computed tomography.
Results: The intoeing gait was caused by increased femoral anteversion in 67.4% of the cases, by internal tibial torsion in 21.7% and by other factors in 10.9%. There was a clear correlation between the degree of femoral anteversion and the degree of external torsion of the tibia.
Conclusion: The results of this study indicate that most common cause of intoeing gait is increased femoral anteversion and that in cases of increased femoral anteversion, compensatory external torsion of the tibia develops during growth.
The posterior tibial nerve was partially blocked with 7% phenol solutions for the relief of severe spasticity in cerebral palsy and brain injured patients. Forty patients were included in this study. Among them thirty five patients were cerebral palsy and five patients were brain injured.
A phenol injection was performed to the posterior tibial nerve at the popliteal fossa with the patients in a prone position. Total injected dose in each patient was 0.40 to 4.00 cc (average 2.06⁑0.96 cc). The dose was far below the toxic level and no significant side effects were noted except for a few cases of local paresthesia and tenderness. The range of dorsiflexion of the ankle was increased and the gait pattern improved in most of the patients one month after the injection. The H-reflex latency was prolonged after the injection compared with the pre-injection latency.
The phenol injection can greatly facilitate the rehabilitation process of the patient by reducing the need for physical therapy and bracing, increasing the patient's ambulation ability, and decreasing the development of secondary leg deformities.
In conclusion, with the easiness, simplicity, safety, low cost, and a selective reduction of spasticity in the group of muscles, the remarkable therapeutic benefits of posterior tibial nerve blocked with 7% phenol solutions warrant the more widespread use of this technique in younger cerebral palsy patients before developing fixed soft tissue contractures.
The purpose of this study was to investigate the maturation characteristics of neonates.
Ninety three neonates underwent a somatosensory evoked potentials(SEPs) testing. Twenty four point seven percent of them were neonates at risks including the neonatal asphyxia, low birth weight under 1500 g, or a suspicious CNS abnormality.
Seventy five point three percent of neonates showed normal median SEPs, and 24.7% of them showed abnormal or a flat response. The mean latency of the first cortical component(N1) was 25.3⁑5.4 msec, duration 16.3⁑5.5 msec and amplitude 1.00⁑1.27 ㄍV.
Thirty one point two percent of neonates showed normal posterior tibial SEPs, and 68.8% showed abnormal or a flat response. The mean latency of the first cortical component(P1) was 44.9⁑5.6 msec, duration 17.5⁑3.9 msec and amplitude 0.47⁑0.38 ㄍV.
This result suggests that the maturation of rostal nervous system develops earlier than the caudal system.
Linear decrease of the cortical latency with post-menstrual age reflects maturation of the central pathway and not merely maturation of the peripheral nerves. But our study showed much less frequency of recordings of the tibial nerve SEPs than the median nerve responses, which suggested that the maturation of spinal cord and lower-limb nerves would be slow, in addition to that the length of pathway was increasing. This result suggests that the maturation of the proximal shorter nervous pathway develops earlier than the distal longer pathway.
The posterior tibial muscle is considered a plantar flexor as well as an invertor of the foot, which acts as a key muscle to the medial longitudinal arch by locking the talar joints in normal gait. Rupture of the posterior tibial tendon can cause a valgus deformity of the hindfoot and an abduction deformity of the forefoot which produces a typical flat foot and a talar dislocation in severe cases.
The tendon of posterior tibial muscle can be ruptured spontaneously after the age of 40 from chronic stress at the ankle joint, or by sports injury and trauma. Severe foot deformity which can be prevented by early diagnosis and appropriate treatment often occurs from misdiagnosis as a chronic ankle sprain or a congenital flat foot.
We report two cases of foot deformities caused by spontaneous and traumatic rupture of posterior tibial tendons with their clinical manifestations and MRI findings.
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