• Physical Therapy Korea
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• v.9 no.1
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• pp.63-68
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• 2002

Foot ulceration results in substantial morbidity in patients with peripheral neuropathy. The purpose of this study was to find the relationship of plantar foot pressures during walking to plantar ulceration in patients with Hansen's disease. The subjects were recuruited from two Welfare Clinic for Hansen's disease in Wonju and Uiwang city. Ten subjects (5 females, 5 males) with plantar ulceration and a mean age of 63 years were evaluated in this study. The mean duration of Hansen's disease in these subjects was 30 years. Plantar pressures were measured during self-selected comfortable walking speed by using MatScan system. Three subjects had plantar ulceration under the first metatarsal head. Five subjects had plantar ulceration under the second and third metatarsal head. Two subjects had plantar ulcers under the fifth metatarsal head. Eight of 10 subjects had plantar ulceration at highest pressure point that measured during walking. This result suggests that the abnormal high plantar pressure could be related factor to plantar ulceration in patients with Hansen's disease. Also the foot pressure measurement may be useful to evaluate the risk of plantar ulceration in patients with Hansen's disease.

• The Journal of Korean Physical Therapy
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• v.30 no.6
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• pp.224-228
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• 2018

Purpose: The most common cause of plantar ulceration is an excessive plantar pressure in patients with peripheral neuropathy. Foot orthosis and therapeutic footwear have been used to decrease the plantar pressure and prevent the plantar ulceration in in diabetes patients. We investigated whether protective sock with functional insoles reduce plantar pressure while walking in 17 diabetes patients. Methods: An in-shoe measurement device was used to measure the peak plantar pressure while walking. Peak plantar pressure data were collected while walking under two conditions: 1) wearing diabetic sock and 2) wearing the protective sock with functional insoles. Each subject walked 3 times in 10-m corridor under three conditions, and data were collected in 3 steps in the middle of corridor with in right and left feet, respectively. Pared t-test was used to compare the peak plantar pressures in three plantar areas under these two conditions. Results: The protective sock with functional insoles significantly reduced the peak plantar pressure on the lateral rearfoot, but significantly increased the peak plantar pressure on the middle forefoot, and medial midfoot (p<0.05). However, there were not significant in medial and lateral forefoot, lateral midfoot, and medial rearfoot between diabetic sock and the protective sock conditions (p>0.05). Conclusion: The protective sock with functional insoles reduced plantar pressures in the rearfoot and supported the medial longitudinal arch. However, it is necessary to change the position of metatarsal pad in the insole design of forefoot area to prevent diabetic foot ulceration.

• Korean Journal of Applied Biomechanics
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• v.19 no.2
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• pp.197-204
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• 2009

It bas been hypothesized that foot ulceration might be internally initiated. Current instruments which merely allow superficial estimate of plantar loading acting on the foot, severely limit the scope of many biomechanical/clinical studies on this issue. Recent studies have suggested that peak plantar pressure may be only 65% specific for the development of ulceration. These limitations are at least partially due to surface pressures not being representative of the complex mechanical stress developed inside the subcutaneous plantar soft-tissue, which are potentially more relevant for tissue breakdown. This study established a three-dimensional and nonlinear finite element model of a human foot complex with comprehensive skeletal and soft-tissue components capable of predicting both the external and internal stresses and deformations of the foot. The model was validated by experimental data of subject-specific plantar foot pressure measures. The stress analysis indicated the internal stresses doses were site-dependent and the observation found a change between 1.5 to 4.5 times the external stresses on the foot plantar surface. The results yielded insights into the internal loading conditions of the plantar soft-tissue, which is important in enhancing our knowledge on the causes of foot ulceration and related stress-induced tissue breakdown in diabetic foot.

• Physical Therapy Korea
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• v.13 no.4
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• pp.64-70
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• 2006

The purpose of this study was to determine whether a relationship existed between foot type and the location of plantar callus in healthy subjects. Twenty-five healthy subjects with plantar callus were recruited for this study. Foot deformities were classified according to the operational definitions as 1) a compensated forefoot varus, 2) an uncompensated forefoot varus or forefoot valgus, or 3) a compensated rearfoot varus. The location of plantar callus was divided into two regions. Fourteen of the 19 feet with compensated forefoot varus and six of the 9 feet showed plantar callus at the second, third or fourth metatarsal head. Five of the 6 feet with uncompensated forefoot varus and twenty of the 16 feet with forefoot valgus showed plantar callus at the first or fifth metatarsal head. A significant relationship was found between foot type and location of callus (p<.01). The results support the hypothesis that certain foot types are associated with characteristic patterns of pressure distribution and callus formation. We believe diabetic patients with insensitive feet and with the types of foot deformity should be fit with foot orthoses and footwears that accommodate their respective deformity in a position as near to the subtalar joint as possible with the goal of preventing plantar ulceration.

• The Journal of Korean Physical Therapy
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• v.19 no.5
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• pp.51-63
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• 2007

Diabetic foot ulcers result from abnormal mechanical loading of the foot, such as repetitive pressure applied to the plantar aspect of the foot while walking. Diabetic peripheral neuropathy causes changes in foot structure, affecting foot function and subsequently leading to increased plantar foot pressure, which is a predictive risk factor for the development of diabetic foot ulceration. To early identify the insensitive foot makes it possible to prevent diabetic foot ulceration and to protect the foot at risk from abnormal biomechanical loading. Abnormal foot pressures can be reduced using several different approaches, including callus debridement, prescription of special footwear, foot orthosis. injection of liquid silicone, Achilles tendon lengthening, and so forth. Off-loading of the diabetic wound is a key factor to successful wound healing as it is associated with reduced inflammatory and accelerated repair processes. Pressure relief can be achieved using various off-loading modalities including accommodative dressing, walking splints, ankle-foot orthosis, total contact cast, and removable and irremovable cast walkers.

• Archives of Reconstructive Microsurgery
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• v.11 no.2
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• pp.153-161
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• 2002

Purpose : Plantar surfaces, calcaneal area, and region of Achilles insertion, which are extremely related with weight-bearing area and shoes application, must be reconstructed with glabrous and strong fibrous skin. Numerous methods of reconstructing defects of these regions have been advocated, but the transfer of similar local tissue as a cutaneous flap with preservation of sensory potential would best serve the functional needs of the weight-bearing and non-weight-bearing surfaces of this region. Therefore it is recommended to use the limited skin of medial surface of foot that is similar to plantar region and non-weight-bearing area. In this paper we performed the medial plantar flap transfered as a fasciocutaneous island as one alterative for moderate-sized defects of the plantar forefoot, plantar heel, and area around the ankle in 25 cases and report the result, availability and problem of medial plantar flap. Materials and methods : We performed proximally based medial plantar flap in 22 cases and reverse flow island flap in 3 cases. Average age was $36.5(4{\sim}70)$ years and female was 3 cases. The causes of soft tissue defect were crushing injury on foot 4 cases, small bony exposure at lower leg 1 case, posterior heel defect with exposure of calcaneus 8 cases, severe sore at heel 2 cases, skin necrosis after trauma on posterior foot 4 cases, and defect on insertion area of Achilles tendon 6cases. Average follow up duration was 1.8(7 months-9.5 years) years. Results: Medial plantar flaps was successful in 22 patients. 18 patients preserved cutaneous branches of medial plantar nerve had sensation on transfered flap but diminished sensation or dysesthesia. At the follow up, we found there were no skin ulceration, recurrence of defect or skin breakdown in all 18 patients. But there was one case which occurred skin ulceration postoperatively among another 4 cases not contained medial plantar nerve. At the last follow up, all patients complained diminished sensation and paresthesia at medial plantar area distally to donor site, expecially with 4 patients having severe pain and discomfort during long-time walking. Conclusion : Medial plantar island flap based on medial plantar neurovascualr pedicle have low failure rate with strong fibrous skin and preserve sensibility of flap, so that it is useful method to reconstruct the skin and soft tissue defect of foot. But it should be emphasized that there are some complications such like pain and paresthesia by neuropraxia or injury of medial plantar nerve at more distal area than donor site. We may consider that medial plantar flap have limited flap size and small arc of rotation, and require skin graft closure of the donor defect and must chose this flap deliberately.

• Physical Therapy Korea
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• v.9 no.3
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• pp.11-21
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• 2002

The purpose of this study was to find the effect of rear foot wedge angle on peak plantar pressures on the forefoot during walking. Twenty normal healthy subjects (10 female, 10 male) were recruited. Peak plantar pressure was measured using pressure distribution platforms (MatScan system) in medial forefoot (under the first, second metatarsal head) and lateral forefoot (under the third, fourth, fifth metatarsal head). The subjects walked at the comfortable velocity under seven conditions; bare footed, $5^{\circ}$, $10^{\circ}$ and $15^{\circ}$ wedges under the medial and lateral sides of the hindfoot. The three averaged peak plantar pressures were collected at each condition at stance and toe off phases. The results showed that a significant increase in lateral forefoot plantar peak pressure investigated in the medial wedge and a significant decrease in lateral forefoot plantar peak pressure investigated in lateral wedge at stance phase (p<.05). These results suggest that rear foot wedge may be useful to modify the peak plantar pressure on the forefoot.

• The Journal of Korean Academy of Orthopedic Manual Physical Therapy
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• v.14 no.1
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• pp.39-47
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• 2008

Purpose : The purpose of this study was to investigate the change of the peak plantar pressure distribution under the foot areas and the range of motion (ROM) of ankle joint according to gradients in treadmill gait. Method : Thirty normal subjects (15 male and 15 female) walked on treadmill at three gradient conditions ($0^{\circ}$, $10^{\circ}$, and $15^{\circ}$) in normal speed. The ankle ROM was measured using the CMS70P that is three dimensional analyzer for excursion of ankle ROM, plantar flexion, and dorsi flexion. The peak plantar pressure distribution under the hallux, 1st metatarsal head (MTH) and heel was measured using the F -Scan system with an in-shoe sensor. Data was collected from 9 steps of left sife foot in at each gradient condition while all subjects walked. Result : As the treadmill gradient increased, the excursion of ankle joint was significantly increased (p<.05). Also, plantar flexion and dorsi flexion was significantly increased according to treadmill gradients (p<.05). The peak plantar pressure under the 1st MTH was significantly increased (p<.05) and the peak plantar pressure under the heel was significantly decreased (p<.05) as the treadmill gradient increased. No significant different in the peak plantar pressure under the hallux was observed. Conclusion : This study suggests that physical therapy for patients who have limited ankle ROM should be considered sufficient range of motion for functional ambulation. And individuals that have painful forefoot syndromes, including metatarsalgia, hallux valgus, and plantar ulceration should be careful in walking to uphill, as there is high plantar pressure under the forefoot.

• Archives of Plastic Surgery
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• v.37 no.2
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• pp.137-142
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• 2010

Purpose: Tumor ablation and traumatic intractable ulceration of the plantar surface of the foot results in skin and soft tissue defects of the weight-bearing sole. Simple skin grafting is not sufficient for reconstruction of the weight-bearing areas. Instead, the island medial plantar flap (instep flap) and distally-based island medial plantar flap was used for proper reconstruction of the weight bearing area. However, there are some disadvantages. In particular, an island medial plantar flap has a short pedicle limiting the mobility of the flap and the distally-based island medial plantar flap is based on a very small vessel. We investigated whether good results could be obtained using a reverse island medial plantar flap based on the lateral plantar vessel as a solution to the above limitations. Methods: Three patients with malignant melanoma were cared for in our tertiary hospital. The tumors involved the lateral forefoot, the postero-lateral heel, and the medial forefoot area. We designed and harvested the flap from the medial plantar area, dissected the lateral and medial plantar artery and vena comitans, and clamped and cut the vessel 1 cm proximal to the branch from the posterior tibial artery and vena comitans. The medial plantar nerve fascicles of these flaps anastomosed to the sural nerve, the 5th interdigital nerve, and the 1st interdigital nerve of each lesion. The donor sites were covered with skin grafting. Results: The mean age of the 3 subjects was 64.7 years (range, 57 - 70 years). Histologically, all cases were lentiginous malignant melanomas. The average size of the lesion was $5.3\;cm^2$. The average size of the flap was $33.1\;cm^2$. The flap color and circulation were intact during the early postoperative period. There was no evidence of flap necrosis, hematomas or infection. All patients had a normal gait after the surgery. Sensory return progressively improved. Conclusion: Use of an island medial plantar flap based on the lateral plantar vessel to the variable weight-bearing sole is a simple but useful procedure for the reconstruction of any difficult lesion of the weight-bearing sole.

• Archives of Plastic Surgery
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• v.37 no.2
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• pp.129-136
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• 2010

Purpose: Anatomically, the foot is provided with insufficient blood supply and is relatively vulnerable to venous congestion compared to other parts of the body. Soft tissue defects are more difficult to manage and palliative treatments can cause hyperkeratosis or ulcer formation, which subsequently requires repeated surgeries. For weight bearing area such as the heel, not only is it important to provide wound coverage but also to restore the protective senses. In these cases, application of flaps for hind foot reconstruction is widely recognized as an effective treatment. In this study, we report the cases of soft tissue reconstruction for which various types of flaps were used to produce good results in both functional and cosmetic aspects. Methods: Data from 37 cases of hind foot operation utilizing flaps performed between from June 2000 to June 2008 were analyzed. Results: Burn related factors were the most common cause of defects, accounting for 19 cases. In addition, chronic ulceration was responsible for 8 cases and so forth. Types of flaps used for the operations, listed in descending order are radial forearm free flap (18), medial plantar island flap (6), rotation flap (5), sural island flap (3), anterolateral thigh free flap (2), lattisimus dorsi muscular flap (2), and contra lateral medial plantar free flap (1). 37 cases were successful, but 8 cases required skin graft due to partial necrosis in small areas. Conclusion : Hind foot reconstruction surgeries that utilize flaps are advantageous in protecting the internal structure, restoring functions, and achieving proper contour aesthetically. Generally, medial plantar skin is preferred because of the anatomical characteristics of the foot (e.g. fibrous septa, soft tissue for cushion). However alternative methods must be applied for defects larger than medial plantar skin and cases in which injuries exist in the flap donor / recipient site (scars in the vicinity of the wound, combined vascular injury). We used various types of flaps including radial forearm neurosensory free flap in order to reconstruct hind foot defects, and report good results in both functional and cosmetic aspects.