Exercise-Associated Muscle Cramps (EAMC) in the calf are common in rugby league. To date, the aetiology and predictors of calf cramping are poorly understood. The aim of this study was to undertake a prospective investigation to identify predictors of calf cramping in rugby league players. Demographic and anthropometric data, as well as calf cramp and injury history, were collected in the preseason. Hydration status, number of games played and calf cramps were recorded on game days. Male rugby league players (n = 103, mean age 18.8 ± 4.1 years) were classified as either EAMC (experienced at least one incident of calf cramps in the season) or no EAMC (no calf cramps). The following were investigated as possible predictors of EAMC using logistic regression modelling: competition level, age, ethnicity, playing position, history of cramping, pre-cramping, low back pain, foot orthotic usage, foot posture, foot strike, muscle flexibility, calf girth, hydration status and number of games played. Half the players, n = 52, experienced at least one incidence of calf cramping. Playing in a senior competition level (OR 0.21; 95% CI 0.06,0.75; p= 0.016), a history of calf cramping (10.85; 2.16,54.44; p=0.004) and a history of low back pain resulting in missed field minutes (4.50, 1.37,14.79; p=0.013) were found to predict EAMC. This study suggests that there is a high incidence of calf cramping in rugby league, especially at senior competition levels, and supports pre-season screening in senior players to identify those at risk of calf cramping and the development of possible preventative strategies.

BACKGROUND:

Current operative treatment options for chronic lateral ankle instability include anatomic repairs utilizing existing local tissue and nonanatomic reconstructions sacrificing the peroneus brevis tendon to mechanically stabilize the ankle. Recent studies have modified these techniques to create an anatomic reconstruction utilizing allograft tendons. The purpose of this study was to retrospectively examine the clinical outcomes of a near-anatomic ligament reconstruction utilizing an allograft tendon for recurrent or complex lateral ankle instability.

METHODS:

Twenty-eight patients underwent a near-anatomic allograft lateral ankle ligament reconstruction with a semitendinosis allograft for severe or recurrent lateral ankle ligamentous instability, and all of them were available for follow-up at an average 32 months. Twelve patients had previously undergone lateral ankle ligament stabilizing surgery, 4 had Ehlers Danlos syndrome with poor local tissue, 5 had greater than 30 degrees of varus angulation of talar tilt, while 12 had associated hindfoot varus requiring concomitant reconstruction. Patients were assessed pre- and postoperatively for Visual Analog Scores (VAS) for pain, Foot and Ankle Ability Measures (FAAM), patient satisfaction, radiographic correction, and complications.

RESULTS:

Median VAS of pain decreased from 8 before surgery to 1 after surgery (P < .001). Median FAAM score increased from 41.7 to 95.2 after surgery (P < .001). Radiographic comparison demonstrated correction of preoperative varus malalignment in all but 1 patient. No patients developed subsequent subtalar arthritis or pain. Three patients had mild persistent instability, all of which was managed nonoperatively. One of the patients with persistent instability also developed chronic regional pain syndrome following surgery. At final follow-up, 25 of 28 patients rated their satisfaction as good or excellent and 3 as fair. No patients required revision surgery.

CONCLUSION:

Lateral ligament reconstruction utilizing a near-anatomically placed and tensioned allograft tendon was a viable option in treating recurrent and complex lateral instability. Not sacrificing the peroneal tendons avoided loss of eversion strength. Near-anatomic placement of the allograft provided good ankle stability without sacrificing subtalar motion or predisposition to subtalar arthritis in short-term follow-up.

Regional anesthesia for blockade of the sciatic nerve in the popliteal fossa is a useful adjunct to pain management in the perioperative setting for foot and ankle surgeons. The present tip aimed to provide a review of the relevant anatomy and technique for popliteal nerve block from the posterior and lateral approaches and to provide discussion and images of the use of peripheral nerve stimulation and ultrasound guidance as adjuvant methods to improve efficacy and reproducibility.

BACKGROUND:

The ankle continues to be one of the most affected joints in the haemophilia patient, and as cartilage damage progresses, the joint can feel unstable, painful and stiff. Anecdotally, patients often report that sports trainers can improve their pain and daily function, however the actual mechanism for this remains unclear.

METHODS:

Nine patients with ankle haemarthropathy and three controls were examined using 'CODAmotion' analysis and a force plate. Kinematic and kinetic variables of the hip, knee and ankle were recorded. Data was imported from CODA to Excel, where a programme using 2D modelling of the ankle joint forces was employed. This calculated intra-articular force from heel strike to toe-off.

FINDINGS:

The haemophilia group at midstance showed an increase in intra-articular force in the ankle when wearing the trainer compared to the shoe (P=<0.05). Overall the haemophilia cohort had an increased joint force in both the trainers and shoes, compared to controls.

INTERPRETATION:

The type of footwear worn by individuals with ankle arthropathy has a significant effect on the amount of force acting at the joint surface. Sports shoes, in providing better comfort and foot support, may facilitate an increased muscular activity around the ankle and therefore improved dynamic joint stability, accounting for why some patients with ankle arthropathy report less pain. Further research is needed to establish levels of acceptable force and the combined effects of orthotics and footwear.

Spinal column infection (vertebral osteomyelitis, discitis, epidural empyema/ abscess) is a rare condition, albeit its incidence has been increasing in recent years. Staphylococcus aureus is the most frequent pathogen. The routes of infection are predominantly hematogenous. Any delay in making correct diagnosis increases risk of adverse outcome of the patient. The authors present 3 case reports of patients with diabetic foot syndrome, who were diagnosed with spondylodicitis in the period of 2009- 2012, two patients had associated epidural empyema. Apart of a chronic neuropathic foot wound, the patients reported severe or deteriorated dorsal pain (2 in the lumbal region, one in thoracic spine), had no new neurologic lesion in the beginning, some had fever, but all had high laboratory parameters of inflammation that did not correlate with local finding on the foot. Methicillinsensitive Staphylococcus aureus cultured from the foot defect in all cases, in two patients from blood cultures and from epidural empyema. They were patients with recurrent local infectious complications of diabetic foot ulcers. Two patients had a concomitant diabetic nephropathy, classified into stages 3- 4/ 5 according to K/ DOQI. Glycemic control (Type 1, Type 2 and secondary DM) ranged from excellent to unsatisfactory (HbA1c 43- 100 mmol/ mol). Apart of patient history and clinical examination, the magnetic resonance imaging of the spine was essential for the diagnosis of spondylodiscitis, or epidural empyema. The treatment was founded on longterm (initially parenteral) antibio-tic treatment, bed rest, then mobilization with orthosis. Neurosurgical procedure was necessary in the patients with epidural empyema. All patients were mobile following a varied time period of convalescence and rehabilitation.

Conclusion:

Dorsal pain and degenerative changes of the spinal column belong to common findings in our population. When searching for the origin of an infection in patients with elevated inflammatory parameters (inadequate finding for a diabetic ulcer), the history of dorsal pain suddenly becomes the fundamental clue for diagnosis of spondylodiscitis with or without epidural empyema. Key words: diabetic foot -  spondylodiscitis -  epidural empyema -  Staphylococcus aureus -  infection.

Schwannomas are rarely seen on the sciatic nerve and can cause sciatica. In this case report we aimed to present an unusual location of schwannoma along sciatic nerve that causes sciatica. A 60-years-old-man was admitted to us with complaints of pain on his thigh and paresthesia on his foot. Radiography of the patient revealed a solitary lesion on the sciatic nerve. The lesion was excised and the symptoms resolved after surgery.

The Foot and Ankle Outcome Score (FAOS) is a patient-reported questionnaire measuring symptoms and functional limitations of the foot and ankle. Aim is to translate and culturally adapt the Dutch version of the FAOS and to investigate internal consistency, validity, repeatability and responsiveness.According to the Cross Cultural Adaptation of Self-Report Measures guideline, the FAOS was translated into Dutch. Eighty-nine patients who had undergone an ankle arthroscopy, ankle arthrodesis, ankle ligament reconstruction or hallux valgus correction completed the FAOS, FFI, WOMAC and SF-36 questionnaires and were included in the validity study. Sixty-five of them completed the FAOS a second time to determine repeatability. Responsiveness was analysed in an additional 15 patients who were being treated for foot or ankle problems.Internal consistency of the FAOS is high (Cronbach's alphas varying between 0.90 and 0.96). Repeatability can be considered good, with ICC's ranging from 0.90 to 0.96. Construct validity can be classified as good with moderate-to-high correlations between the FAOS subscales and subscales of the FFI (0.55 to 0.90), WOMAC (0.57 to 0.92) and SF-36 subscales physical functioning, pain, social functioning and role-physical (0.33 to 0.81). Low standard response means were found for responsiveness (0.0 to 0.4).The results of this study show that the Dutch version of the FAOS is a reliable and valid questionnaire to assess symptoms and functional limitations of the foot and ankle.

AIM:

To identify the factors responsible for the low health-related quality of life associated with foot ulcers and the relative importance of these factors.

METHODS:

A total of 1232 patients with a new foot ulcer, who presented at one of the 14 centres in 10 European countries participating in the Eurodiale study, were included in this cross-sectional study. Patient and ulcer characteristics were obtained as well as results from the Euro-Qol-5D questionnaire, a health-related quality of life instrument with five domains (mobility, self-care, usual activities, pain/discomfort and anxiety/depression). To analyse the relative importance of comorbidities and ulcer- and patient-related factors for health-related quality of life, linear regression models were used to calculate the relative contributions of each factor to the fit (R(2) ) of the model.

RESULTS:

Patients reported poor overall health-related quality of life, with problems primarily in the mobility and pain/discomfort domains. Among the comorbidities, the inability to stand or walk without help was the most important determinant of decreased health-related quality of life in all five domains. Among ulcer-related factors, ulcer size, limb-threatening ischaemia and elevated C-reactive protein concentration also had high importance in all domains. The clinical diagnosis of infection, peripheral arterial disease and polyneuropathy were only important in the pain/discomfort domain.

CONCLUSIONS:

The factors that determine health-related quality of life are diverse and to an extent not disease-specific. To improve health-related quality of life, treatment should not only be focused on ulcer healing but a multifactorial approach by a specialized multidisciplinary team is also important. This article is protected by copyright. All rights reserved.

The plantar heel pad is a specialised fibroadipose tissue that attenuates and dissipates, in part, the impact energy associated with heel strike. Although near maximal deformation of the heel pad has been shown to occur during running,(1) in vivo measurement of the mechanical properties of the heel pad during walking remain largely unexplored. This study used a digital fluoroscope, synchronised with a pressure plate, to obtain force-deformation data for the heel pad during walking.Dynamic lateral foot radiographs were acquired from sixteen healthy adults while walking at their preferred speed. Sagittal thickness and deformation of the heel pad relative to the support surface were calculated. Simultaneous measurement of peak force beneath the heel was used to estimate the principal structural properties of the heel pad.Transient loading profiles associated with walking induced rapidly changing deformation rates in the heel pad and resulted in irregular load-deformation curves. The initial stiffness (32±11 N.mm-1) of the heel pad was an order of magnitude lower than its final stiffness (212±125 N.mm-1) and only 1.0 J of energy, on average, was dissipated by the heel pad during walking. Peak deformation (10.3 mm) approached that predicted for the limit of pain tolerance (10.7 mm).Peak deformation of the heel pad approached that predicted for the limit of pain tolerance,(2) suggesting the heel pad operates close to its pain threshold even at speeds encountered during walking. These findings raise questions as to the function of the heel pad during gait, highlight the need for alternative energy dissipating mechanisms during high impact activities often encountered in sport, and provide insight as to why barefoot runners adopt 'forefoot' strike patterns that minimise heel loading.