title: Contribution of plantar fascia to the increased forefoot pressures in diabetic patients.
abstract: OBJECTIVE
  Secondary to peripheral neuropathy, plantar hyperpressure is a proven risk factor for foot ulceration. But limited joint mobility (LJM) and soft tissue abnormalities may also contribute. The aim of this study was to evaluate the relationships among thickness of plantar fascia, mobility of the metatarso-phalangeal joint, and forces expressed under the metatarsal heads.
  
  
  METHODS
  We evaluated 61 diabetic patients: 27 without neuropathy (D group), 19 with neuropathy (DN group), and 15 with previous neuropathic foot ulceration (DNPU group). We also examined 21 control subjects (C). Ultrasound evaluation was performed with a high resolution 8- to 10-MHz linear array (Toshiba Tosbee SSA 240). The foot loading pattern was evaluated with a piezo-dynamometric platform. First metatarso-phalangeal joint mobility was assessed with a mechanic goniometer.
  
  
  RESULTS
  Diabetic patients presented increased thickness of plantar fascia (D 2.9 +/- 1.2 mm, DN 3.0 +/- 0.8 mm, DNPU 3.1 +/- 1.0 mm, and C 2.0 +/- 0.5.mm; P < 0.05), and significantly reduced motion range at the metatarso-phalangeal joint (D 54.0 +/- 29.4 degrees, DN 54.9 +/- 17.2 degrees, DNPU 46.8 +/- 20.7 degrees, and C 100.0 +/- 10.0 degrees; P < 0.05). The evaluation of foot-floor interaction under the metatarsal heads showed increased vertical forces in DN and DNPU and increased medio-lateral forces in DNPU. An inverse correlation was found between the thickness of plantar fascia and metatarso-phalangeal joint mobility (r = -0.53). The thickness of plantar fascia was directly correlated with vertical forces under the metatarsal heads (r = 0.52).
  
  
  CONCLUSIONS
  In diabetic patients, soft tissue involvement may contribute to the increase of vertical forces under the metatarsal heads. Changes in the structure of plantar fascia may also influence the mobility of the first metatarso-phalangeal joint.
authors.affiliation: Department of Internal Medicine, Tor Vergata University of Rome, Italy.
authors.forename: Emanuela
authors.initials: E
authors.lastname: D'Ambrogi
authors.forename: Laura
authors.initials: L
authors.lastname: Giurato
authors.forename: Maria Antonietta
authors.initials: MA
authors.lastname: D'Agostino
authors.forename: Claudia
authors.initials: C
authors.lastname: Giacomozzi
authors.forename: Velio
authors.initials: V
authors.lastname: Macellari
authors.forename: Antonella
authors.initials: A
authors.lastname: Caselli
authors.forename: Luigi
authors.initials: L
authors.lastname: Uccioli
mesh_terms: D048909:Diabetes Complications; D003920:Diabetes Mellitus / Q000503:physiopathology; D003929:Diabetic Neuropathies / Q000503:physiopathology; D036981:Fasciitis, Plantar / Q000150:complications*; D005260:Female; D005528:Foot; D016523:Foot Ulcer / Q000503:physiopathology; D006801:Humans; D008297:Male; D008683:Metatarsophalangeal Joint / Q000502:physiology / Q000503:physiopathology; D008875:Middle Aged; D011312:Pressure; D012016:Reference Values; D012044:Regression Analysis; D013314:Stress, Mechanical; D040521:Subcutaneous Tissue / Q000502:physiology* / Q000503:physiopathology