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OBJECTIVE: To test the feasibility of applying the magnetic resonance elastography (MRE) technique to map the elastic modulus of the plantar fat pads in diabetic and nondiabetic subjects.
METHODS: A prototype MRE imaging apparatus was used to produce quantitative maps of the heel fat pad in a pilot study of 12 volunteers and 4 patients with diabetes with neuropathy. Anatomic images corresponding to MRE maps allowed precise selection of regions of interest in the fat.
RESULTS: Magnetic resonance elastograms of the heel fat pads were successfully created; mean measurements in the volunteers and the diabetic patients were 4.85 and 5.26 kPa, respectively.
CONCLUSION: It is feasible to perform MRE on the plantar fat pads and to produce elasticity maps. The trend toward stiffer fat pads, as demonstrated in patients with diabetes, suggests that the fat pads were qualitatively different. Magnetic resonance elastography offers great potential to investigate the mechanical properties of soft tissues in vivo noninvasively.
Over the last decade research has been conducted into the mechanical properties of the heel pad. Previous and current studies have used ultrasound and finite element modelling to evaluate the heel pad in the healthy and patient population. I have listed a number of references that may help the reader understand the role the heel pad in musculoskeletal conditions such as plantar heel pain, measurement and diabetes.
Finite Element Analysis
Erdemir A, Viveiros, ML, Ulbrecht JS, Cavanagh PR (2006): An inverse finite-element model of heel-pad indentation. J Biomech 39:1279-1286.
Spears IR, Miller-Young (2006): The effects of heel-pad thickness and loading protocols on heel pad stiffness. Clin Biomech 21: 204-212.
Spears I, Miller-Young J, Waters M, Rome K, (2005). Effect of loading conditions on stress in the barefoot heel pad. Medicine & Science in Sports & Exercise 37: 1030-1036.
Ultrasound Measurements
Uzel M, Centinus E, Bilgic E, Ekerbicer H, Karaguz A (2006): Comparison of ultrasonography and radiography in assessment of the heel pad compressibility index of patients with plantar heel pain syndrome. Joint Bone Spine 73: 196-199.
Uzel M, Centinus E, Bilgic E, Ekerbicer H, Karaguz A (2006): Heel pad thickness and athletic activity in healthy young adults: a sonographic study. J Clin Ultrasound 34: 231-236.
Tong J. Lim CS. Goh OL (2003): Technique to study the biomechanical properties of the human calcaneal heel pad. Foot: 13: 83-91.
Rome K, Campbell R, Flint A, Haslock I (1998). Variability in the measurement of heel pad thickness. Br J Radiology 71: 1149-1152.
Rome K, Campbell R, Flint A, Haslock I (1998). Measurement of weight-bearing heel pad thickness. Clin Biomech 13: 374-375.
Diabetes
Hsu TC. Lee YS. Shau YW (2002): Biomechanics of the heel pad for type 2 diabetic patients. Clin Biomech 17:291-6.
Hsu TC. Wang CL. Shau YW. Tang FT. Li KL. Chen CY (2000): Altered heel-pad mechanical properties in patients with Type 2 diabetes mellitus. Diabetic Med 17:854-9.
Mechanical Properties
Tsai WC. Wang CL. Hsu TC. Hsieh FJ. Tang FT (1999): The mechanical properties of the heel pad in unilateral plantar heel pain syndrome. Foot Ankle 20:663-8.
Wang CL. Hsu TC. Shau YW. Wong MK (1998): Variations in heel pad mechanical properties variation between children and young adults. J Formosan Med Ass 97:850-4.
Hsu TC. Wang CL. Tsai WC. Kuo JK. Tang FT (1998): Comparison of the mechanical properties of the heel pad between young and elderly adults. Arch Phys Med Rehabil 79:1101-4.
Rome K, Webb P (2000). Development of an instrument to measure heel pad stiffness. Clinical Biomechanics: 15: 298-300.
Plantar Heel Pain
Turgut A. Gokturk E. Kose N. Seber S. Hazer B. Gunal I (1999): The relationship of heel pad elasticity and plantar heel pain. Clin Orthop Rel Res 360:191-6.
Rome K, Campbell R, Flint A (2002). Heel pad thickness: a predictor in the development of plantar heel pain. Foot Ankle 32: 31-35.
Rome K, Webb P, Haslock I, Unsworth T (2001): Heel pad stiffness in runners. Clin Biomech 35: 205-209.
Rome K, Campbell R, Flint A, Haslock I (2000): Biological and anatomical risk factors associated with the development of plantar heel pain in athletes. Med Sci Sports Exerc 32: S127.
Over the last decade research has been conducted into the mechanical properties of the heel pad. Previous and current studies have used ultrasound and finite element modelling to evaluate the heel pad in the healthy and patient population. I have listed a number of references that may help the reader understand the role the heel pad in musculoskeletal conditions such as plantar heel pain, measurement and diabetes.
Keith:
Thanks for all those references. That's a great resource of information. :)
Currently, there seems to be some controversy regarding the mechanical etiology of plantar heel pain, or what clinicians commonly call proximal plantar fasciitis. Most podiatrists believe that proximal plantar fasciitisit is due to a tensile force on the plantar fascia and/or plantar intrinsics (caused by "overpronation") whereas, from yours and others research, plantar heel pain may also be caused by injury to the plantar heel structures from impact with the ground (i.e. excessive compression forces).
Considering your list of papers and your research regarding the mechanical characteristics of the plantar heel fat pad, I would gratefully appreciate it if you could answer these questions for me:
1. Of the plantar heel pain that is seen in today's population, what proportion of it is likely due to compression forces on the plantar heel vs. due to tension forces on the soft tissue structures that attach to the plantar heel? (Of course, a change in plantar heel fat pad mechanical characterisitics would most likely affect the plantar heel pain cause by compression forces more than that caused by tension forces.)
I realize that you probably don't have any population studies to back up any opinions but I would still like you to comment on this. It seems reasonable to assume that if the exact mechanical etiology of plantar heel pain is known then certainly this knowledge may enable the clinician to achieve better therapeutic results in treating this common and painful pathology.
2. Is there any good clinical way that you know of to diagnose whether plantar heel pain is due to excessive tension stress or excessive compression stress on the plantar heel?
One test I use is to ask the patient whether the pain with walking is more at heel contact, when the plantar heel strikes the ground and receives its greatest magnitudes of compression loads, or whether the pain is more when the foot is at the end of late midstance, when the plantar fascia has been shown to be subjected to the greatest magnitudes of tension loads. If you know of any other tests or clinical pearls, then that would be useful information.
3. What measure of mechanical characteristics of the plantar heel fat pad (i.e. heel pad thickness, stiffness, elasticity, or elastic modulus) is most predictive of plantar heel pain and plantar heel injury?
4. Is there any ongoing research on possibly developing a surgical procedure to restore the optimum mechanical characteristics of the plantar heel fat pad?
I'm sure your answers will help generate great interest in this fascinating subject that you have done so much original research in. Thanks for your expertise and time, Keith.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
1. Of the plantar heel pain that is seen in today's population, what proportion of it is likely due to compression forces on the plantar heel vs. due to tension forces on the soft tissue structures that attach to the plantar heel? (Of course, a change in plantar heel fat pad mechanical characteristics would most likely affect the plantar heel pain cause by compression forces more than that caused by tension forces.)
I realize that you probably don't have any population studies to back up any opinions but I would still like you to comment on this. It seems reasonable to assume that if the exact mechanical aetiology of plantar heel pain is known then certainly this knowledge may enable the clinician to achieve better therapeutic results in treating this common and painful pathology.
The exact cause of plantar heel pain is not known. The actual mechanism, i.e. compression forces on the plantar heel or tension force on the soft tissue is open to debate. Previous studies have suggested that vertical ground reaction forces are not related to plantar heel pain under laboratory conditions. Finite modelling suggests that excessive stress upon the soft tissue over time could be a contributing factor in the development of plantar heel pain. My thoughts relate to inflammation of the fat pad surrounding the calcanuem. We postulated, and I mean postulate!, that excessive oedema of the soft tissue over time leads to a deficiency in the shock attenuating properties of the heel pad at heel-strike leading to the classical symptoms of first-step heel pain and a dull-ache at the end of the day due to the accumulation of fluid. If you then add excessive BMI and age then a clearer picture emerges.
Liddle D, Rome K, Howe T (2000). Comparison of vertical ground reaction forces in subjects with plantar heel pain. Gait & Posture: 11: 62-66.
Spears I, Miller-Young J, Waters M, Rome K, (2005). Effect of loading conditions on stress in the barefoot heel pad. Medicine & Science in Sports & Exercise 37: 1030-1036.
Rome K, Campbell R, Flint A (2002). Heel pad thickness: a predictor in the development of plantar heel pain. Foot & Ankle International: 32: 31-35.
Rome K, Webb P, Haslock I, Unsworth T (2001). Heel pad stiffness in runners. Clinical Biomechanics 35: 205-209
From a clinical perspective, a common belief among practitioners is that excessive foot pronation is the major, in some instances the only cause of plantar heel pain. Foot orthoses have been therefore advocated. My thoughts: plantar heel pain is a complex multi-factorial musculoskeletal condition that is dependent upon the living style of the person, physical activities (or lack of) and the environment in which the physical activities takes place. For example, why does a young female long-distance runner develop heel pain OR an overweight male factory-worker standing for 8 hours/day on a hard surface develop heel pain? A thorough case history should be taken than includes all risk factors associated with plantar heel pain. Risk factors can be divided into intrinsic (foot type, range of motion at all major foot and ankle joints, BMI and previous injury) and extrinsic factors (footwear, work environment, physical activities and quality of life issues).
2. Is there any good clinical way that you know of to diagnose whether plantar heel pain is due to excessive tension stress or excessive compression stress on the plantar heel?
One test I use is to ask the patient whether the pain with walking is more at heel contact, when the plantar heel strikes the ground and receives its greatest magnitudes of compression loads, or whether the pain is more when the foot is at the end of late midstance, when the plantar fascia has been shown to be subjected to the greatest magnitudes of tension loads. If you know of any other tests or clinical pearls, then that would be useful information.
I must confess I am not familiar with any clinical tests to differentiate between compressive and tensile stress. Have your clinical tests been validated? It would be interesting to cross-validate the clinical tests to kinematic data and to use finite-element modelling to validate the stresses and strains of the soft tissue.
3. What measure of mechanical characteristics of the plantar heel fat pad (i.e. heel pad thickness, stiffness, elasticity, or elastic modulus) is most predictive of plantar heel pain and plantar heel injury?
My previous research identified a number of risk factors for the prediction of plantar heel pain among a large group of runners that participated in physical activity. A significant difference in heel pad thickness was observed between plantar heel pain subjects, and non-plantar heel pain subjects and an age-matched control group. Prediction of plantar heel pain was analysed by applying a forward multiple logistic regression analysis. The initial multivariate model identified running all year, participating in squash/aerobics, age, heel pad thickness and stiffness as significant predictors (p< 0.05). Of these, age, heel pad thickness and heel pad stiffness were identified as independent statistical variables in predicting plantar heel pain in the final multivariate model (p<0.05). No significant interaction was found between the risk factors that contributed to the chance of developing plantar heel pain. The strongest predictors for plantar heel pain were age group (OR = 4.4) and heel pad thickness (OR = 1.9). Prediction of risk factors was poor, with only 20% of subjects with plantar heel pain correctly predicted. This suggests that other risk factors may play a role in the development of plantar heel pain (Rome et al, 2001).
An excellent systematic review has just been published by Irving et al (2006) which demonstrate weak, moderate and strong predictors of plantar heel pain. My response to the article is also found in the same edition.
Irving DB, Cook JL, Menz HB (2006): Factors associated with chronic plantar heel pain: a systematic review. Journal of Science and Medicine in Sport Australia 9: 11-22.
Rome K (2006): in response to Irving DB, Cook JL, Menz HB (2006): Factors associated with chronic plantar heel pain: a systematic review. Journal of Science and Medicine in Sport Australia 9: 23-24.
Rome K (2001): Howe T, Haslock I (2001): Anatomical and biological risk factors associated with the development of plantar heel pain. The Foot 11: 119-125.
4. Is there any ongoing research on possibly developing a surgical procedure to restore the optimum mechanical characteristics of the plantar heel fat pad?
Although I am not a surgeon a key feature that is essential to any surgical procedure is the maintenance of the fat pad. Nack and Phillips (1990) quoted any steps that can be taken to preserve the architecture and density of the calcaneal fat pad should be taken. Furthermore, from reading the literature one of the post-operative complications of surgery is transient swelling of the heel pad. Therefore, maintaining the structure of the heel pad is crucial (Rome and Saxelby, 2005).
Nack JD, Phillips RD: Shock absorption. Clinics in Podiatric Medicine & Surgery 7:391-7, 1990.
Rome K, Saxelby J (2005): Assessment and management of plantar fasciitis critical review. British Journal of Podiatric Medicine 8: 34-44.
Is there any good clinical way that you know of to diagnose whether plantar heel pain is due to excessive tension stress or excessive compression stress on the plantar heel?
One test I use is to ask the patient whether the pain with walking is more at heel contact, when the plantar heel strikes the ground and receives its greatest magnitudes of compression loads, or whether the pain is more when the foot is at the end of late midstance, when the plantar fascia has been shown to be subjected to the greatest magnitudes of tension loads. If you know of any other tests or clinical pearls, then that would be useful information.
Quote:
Originally Posted by Keith Rome
I must confess I am not familiar with any clinical tests to differentiate between compressive and tensile stress. Have your clinical tests been validated? It would be interesting to cross-validate the clinical tests to kinematic data and to use finite-element modelling to validate the stresses and strains of the soft tissue.
Upon considering the dual-stress nature of plantar heel pain, I came up with this clinical test to try to differentiate the mechanical nature of the etiology of the tissue damage on the plantar heel a few years ago. It is interesting to ask patients when, during the walking gait cycle, the pain occurs most since the response varies significantly from patient to patient. Some patients say the pain only occurs at heel strike, others say the pain only occurs during late midstance and others say it hurts all the way from contact phase to toe off. I have no clue how you would know if the injury is more likely being caused by compressive or tensile stress otherwise in order to validate this test. But I believe the test does give the clinician one more clue to go with that may help make the patient better in the long run.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Would you then tailor a trial treatment regime base on the response of when the pain was at it's worse?
I also ask the same question as to when is the pain at it's worse during the gait. What I do is if someone says that the pain is worse at contact I strap a basket weave technique around the heel in an effort pull the fat pad back around the heel. While if the pain is more when someone is in midstance to toe off I focus more on a low dye strapping in an effort to reduce the tensional stress. Is this what you and others would do?
regards
__________________
Mark Egan
Absolute Podiatry
331/33 North St
Spring Hill, Qld
4000
Would you then tailor a trial treatment regime base on the response of when the pain was at it's worse?
I also ask the same question as to when is the pain at it's worse during the gait. What I do is if someone says that the pain is worse at contact I strap a basket weave technique around the heel in an effort pull the fat pad back around the heel. While if the pain is more when someone is in midstance to toe off I focus more on a low dye strapping in an effort to reduce the tensional stress. Is this what you and others would do?
regards
Mark:
If the heel pain is compression related, I will be more likely to prescribe soft-shock absorbing heel cushions, have the patient avoid any barefoot walking or hard surfaces, etc. If it is tension related then I will tend to get them into higher heeled shoes, do more calf stretching, use night splints, etc. Of course, I believe that most plantar heel pain is both compression and tension related, but it does help to have a method to get a better idea of which abnormal stress is the cause of most of the pain.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
BACKGROUND: The original purpose of the study was to clarify whether or not there is continuity of the Achilles tendon and the plantar fascia. Those findings have been previously published. In the course of that study, observations of the anatomy of the retinacular tethers of the heel pad were made. These observations included the discovery of the medial calcaneal retinaculum.
METHODS: Ten adult cadaver feet were dissected. A longitudinal midline incision was made along the Achilles tendon and on the plantar surface of the foot. The heel pad was incised and the skin and heel pad were reflected side-to-side to reveal the calcaneal tuberosity. In this way the retinacular tethers of the heel pad could be seen.
RESULTS: Two types of retinacular fibers were observed. Abundant small retinacula were seen coming off the plantar fascia and calcaneal tuberosity. Less abundant larger retinacula originated from the calcaneus only. Both types anchored the heel pad by branching into the fibrous stroma of the heel pad. In nine of 10 feet, a much larger retinacular structure was the principle tether of the heel pad to the medial process of the calcaneal tuberosity. We named this the medial calcaneal retinaculum.
CONCLUSIONS: The heel pad is anchored by retinacula that vary in number, location, and size. The most consistent and significant tether of the heel pad appears to be the medial calcaneal retinaculum.
CLINICAL RELEVANCE: Dislocation of the fat pad of the heel is a relatively rare but potentially devastating injury. An understanding of the anatomical anchoring of the heel pad and its mechanical function can lead to a surgical procedure to restore stability to the heel pad.
Microchambers and Macrochambers in Heel Pads: Are They Functionally Different? J Appl Physiol. 2007 Feb 1;
Hsu CC, Tsai WC, Wang CL, Pao SH, Shau YW, Chuan YS
Quote:
The heel pad consists of a superficial microchamber layer and a deep macrochamber layer. This study highlights the different biomechanical behaviors between the microchamber and macrochamber layers using ultrasonography. The heel-pad in each left foot of six healthy volunteers aged about 25 years old were measured with a device consisting of a 10-MHz linear-array ultrasound transducer and a load cell. The testing heels were loaded on the ultrasound transducer with a loading velocity of approximately 0.5 cm/s and were withdrawn when the specified maximum stress (158 kPa) was reached. Unloaded tissue thickness, end-loaded thickness, deformation proportion, average deformation and rebound rates and elastic modulus of the microchamber and macrochamber layers were assessed. The unloaded thickness of the microchamber layer was approximately 30 % of the macrochamber layer. The microchamber layer also had significantly less unloaded thickness, end-loaded thickness, mean deformation rate, mean rebound rate and deformation proportion than the macrochamber layer. A significant difference between the unloaded and end-loaded thickness in the macrochamber layer was observed. The average soft tissue deformation rate was significantly different from the rebound rate in the microchamber layer. A similar trend was detected in the macrochamber layer. The elastic modulus of the microchamber layer was 450+/-240 kPa, which was nearly 10 times of that in the macrochamber layer. In conclusion, ultrasound can identify the heterogeneous tissue properties of the heel pad. The macrochamber layer responds to loading with large deformation and the microchamber layer has a high degree of tissue stiffness.
The plantar soft tissue is the primary means of physical interaction between a person and the ground during locomotion. Dynamic loads greater than body weight are borne across the entire plantar surface during each step. However, most testing of these tissues has concentrated on the structural properties of the heel pad. The purpose of this study was to determine the material properties of the plantar soft tissue from six locations beneath: the great toe (subhallucal), the 1st, 3rd and 5th metatarsal heads (submetatarsal), the lateral midfoot (lateral submidfoot) and the heel (subcalcaneal). We obtained specimens from these locations from 11 young, non-diabetic donors; the tissue was cut into 2cmx2cm blocks and the skin was removed. Stress relaxation experiments were conducted and the data were fit using the quasi-linear viscoelastic (QLV) theory. To determine tissue modulus, energy loss and the effect of test frequency, we also conducted displacement controlled triangle waves at five frequencies ranging from 0.005 to 10Hz. The subcalcaneal tissue was found to have an increased relaxation time compared to the other areas. The subcalcaneal tissue was also found to have an increased modulus and decreased energy loss compared to the other areas. Across all areas, the modulus and energy loss increased for the 1 and 10Hz tests compared to the other testing frequencies. This study is the first to generate material properties for all areas of the plantar soft tissue, demonstrating that the subcalcaneal tissue is different than the other plantar soft tissue areas. These data will have implications for foot computational modeling efforts and potentially for orthotic pressure reduction devices.
Mechanical properties of the human heel pad: a comparison between populations.
Rchallis JH, Murdoch C, Winter SL. J Appl Biomech. 2008 Nov;24(4):377-81.
Quote:
The purpose of this study was to compare the heel pad mechanical properties of runners, who repetitively load the heel pad during training, with cyclists who do not load their heel pads during training. Ten competitive long distance runners and 10 competitive cyclists volunteered for this study. The thickness of the unloaded heel pad was measured using realtime B-mode ultrasonography. A heel pad indentation device was used to measure the mechanical properties of the heel pads. To evaluate the differences between the two groups, in heel pad properties, a repeat measures analysis of variance was used (p <.05.) Heel pad thickness was not different between groups when normalized with respect to subject height. There was no significant difference between the groups in percentage energy loss during loading and unloading (runners: 61.4% +/- 8.6; cyclists: 62.5% +/- 4.6 ). Heel pad stiffness for the runners was statistically significantly less than that of the cyclists (p = .0018; runners: 17.1 N. -1 +/- 3.0; cyclists: 20.4 N. -1 +/- 4.0). These results indicate that the nature of the activity undertaken by individuals may influence their heel pad properties. This finding may be important when considering differences in heel pad properties between different populations.
Bulk compressive properties of the heel fat pad during walking: A pilot investigation in plantar heel pain
Scott C. Wearing, James E. Smeathers, Bede Yates, Stephen R. Urry, Philip Dubois Clinical Biomechanics (in press)
Quote:
Background
Altered mechanical properties of the heel pad have been implicated in the development of plantar heel pain. However, the in vivo properties of the heel pad during gait remain largely unexplored in this cohort. The aim of the current study was to characterise the bulk compressive properties of the heel pad in individuals with and without plantar heel pain while walking.
Methods
The sagittal thickness and axial compressive strain of the heel pad were estimated in vivo from dynamic lateral foot radiographs acquired from nine subjects with unilateral plantar heel pain and an equivalent number of matched controls, while walking at their preferred speed. Compressive stress was derived from simultaneously acquired plantar pressure data. Principal viscoelastic parameters of the heel pad, including peak strain, secant modulus and energy dissipation (hysteresis), were estimated from subsequent stress–strain curves.
Findings
There was no significant difference in loaded and unloaded heel pad thickness, peak stress, peak strain, or secant and tangent modulus in subjects with and without heel pain. However, the fat pad of symptomatic feet had a significantly lower energy dissipation ratio (0.55±0.17 vs. 0.69±0.08) when compared to asymptomatic feet (P<.05).
Interpretation
Plantar heel pain is characterised by reduced energy dissipation ratio of the heel pad when measured in vivo and under physiologically relevant strain rates.
BACKGROUND: The study attempted to highlight the differences of mechanical properties in microchambers and macrochambers between patients with type 2 diabetes mellitus and age-matched healthy volunteers.
METHODS: A total of 29 heels in 18 diabetic patients and 28 heels in 16 age-matched healthy participants were examined by a loading device consisting of a 10-MHz compact linear-array ultrasound transducer, a Plexiglas cylinder, and a load cell. Subjects in both groups were on average about 55years old with a body mass index of approximately 25kg/m(2). A stepping motor was used to progressively load the transducer on the tested heels at a velocity of 6mm/s from zero to the maximum stress of 78kPa. Unloaded thickness, strain, and elastic modulus in microchambers, macrochambers and heel pads were measured.
FINDINGS: Microchambers strain in diabetic patients was significantly greater than that in healthy subjects (0.291 (SD 0.14) vs. 0.104 (SD 0.057); P<0.001). Macrochambers strain in diabetic patients was significantly less than that in healthy subjects (0.355 (SD 0.098) vs. 0.450 (SD 0.092); P=0.001). Microchambers stiffness in diabetic patients was significantly less than that in healthy persons (393 (SD 371)kPa vs. 1140 (SD 931)kPa; P<0.001). Macrochambers stiffness in diabetic patients was significantly greater than that in healthy persons (239 (SD 77)kPa vs. 181 (SD 42)kPa; P=0.001).
INTERPRETATION: Heel pad tissue properties are altered heterogeneously in people with diabetes. Increased macrochambers but decreased microchambers stiffness may cause diminished cushioning capacities in diabetic heels
Plantar fat pad properties
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