Foot Neuropathy - Role of HyProCure
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Transcript of Foot Neuropathy - Role of HyProCure
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Dynamic Effect of Hyperpronation on the
tarsal tunnel & posterior Tibial nerve
Michael E. Graham, DPM, FACFASShelby Township, Michigan
Inventor-HyProCure, Founder/CEO GraMedica
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How is it that patients with a very diverse medical background or no
medical issues have the same peripheral nerve symptoms?
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SameSymptoms
Diabetes
IdiopathicHereditary
MedicationsHeavy Metals
Alcohol
Current Primary Etiologic Factors
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What is the “Golden Thread” that connects these individuals?
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What are our patients telling us?
• The more active I am the worse the symptoms.• The more I am off my feet, or the less active I
am, the less the symptoms.
• “Functional Symptoms”.• There must be a biomechanical component to
this disease process.
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Obviously-where are they in the disease process determines the severity of their symptoms
• Grade 0• Grade I• Grade II• Grade III• Grade IV• Grade V
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Posterior Tibial Nerve Study
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Excessive Hindfoot Motion
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Normal TaloTarsal Motion
• 1/3 Pronation• 2/3 Supination
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Tarsal Tunnel Pressures- What do we know?
Neutral STJ 2 (0-7) mmHgMaximally pronated 32 (12-60) mmHgPronation = significantly increases pressure within
the tarsal tunnel with every step taken
Kumar et al: Evaluation of Various Fibro-Osseous Tunnel Pressures in Normal Human Subjects. Indian J Physiol Pharmaol, 32:139-145, 1988
Trepman et al.:Effect of Foot & Ankle Position on Tarsal Tunnel Compartment Pressure. Foot Ankle Int. 20:721-726, 1999
Barker et al: Pressures Changes in the Medial & Lateral Plantar and Tarsal Tunnels Related to Ankle Position: A Cadaver Study. Foot Ankle Int 28:250-254, 2007
Rosson et al: Tibial Nerve Decompression in Patients with Tarsal Tunnel Syndrome: Pressures in the Tarsal, Medial Plantar, and Lateral Plantar Tunnels. Plast Reconstr Surg 124:1202-1210, 2009
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Increased Tarsal Tunnel PressuresWhat do we know?
• A pressure of 20 – 30 mmHg has been shown to impair intraneural blood flow
– Gelberman et al: Tissue Pressure Threshold for Peripheral Nerve Viability. Clin Orthop Relat Res 285-291, 1983
– Rydevik et al: Effects of graded comprssion of intraneural blood flow. An in vivo study on rabbit tibial nerve. J Hand Surg AM 6:3-12, 1981
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Nerve Strain/TensionWhat do we know?
• Pronation increases the strain/tension on the posterior tibial nerve
– Francis et al: Benign Joint Hypermobility with Neuropathy: Documentation and Mechanism of Tarsal Tunnel Syndrome. J Rheumatol 14:577-581, 1987
– Daniels et al: The Effects of Foot Position and Load on Tibial Nerve Tension. Foot Ankle Int. 19:73-78, 1998
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Nerve Strain/TensionWhat do we know?
• 8% venular flow obstructs• 15% complete arterial occlusion occurs
– Kwan el al: Strain, stress, and stretch of peripheral nerve. Acta Orthop Scand, 83:267-272, 1992
– Lundborg, G, Rydevik, B: Effects of stretching the tibial nerve of the rabbit. JBJS 55B:390-401, 1973
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Nerve Strain/TensionWhat do we know?
• 6 % Strain decreases the amplitude of the action potential which recovers after removal of the strain.
• 12% strain produced a complete block and showed minimal recovery
– Wall et al: Experimental stretch neuropathy. JBJS 74B:126-129, 1992
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Putting it all together
• Pronation increases pressure within the tarsal tunnel which interrupts intraneural blood flow
• Pronation increases nerve strain/tension
• In a normal amount of pronation• What about a hyperpronating foot• Average person takes 7,000-10,000 steps per day• 50 y.o. has taken roughly 152,022,500 steps
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How can we eliminate the Hyperpronation?
• Orthotics?• Special Shoes• Braces/splints• Exercises/stretching
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Custom-molded “Orthotics”can actually make the condition worse!
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Normal to abnormal alignmenttalus drops forward and down
www.hyprocure.com
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Two Part Study
Hyperpronating footStabilized Hindfoot
With HyProCure
• Pressure Measurements within the – Tarsal Tunnel– Porta Pedis
• Strain of the Posterior Tibial Nerve Elongation in a hyperpronating foot.
• Pressure Measurements within the – Tarsal Tunnel– Porta Pedis
• Strain of the Posterior Tibial Nerve Elongation in a hyperpronating foot.
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Part I findings
Pressure Measurements
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Cadaver Set-Up
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Tarsal Tunnel
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Porta Pedis
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TT Pressures Without HyProCure With HyProCure
% Reduction HyProCure
Specimen No. Neutral
Hyper-Pronated Neutral
Hyper-Pronated
n = 3 for each reported data value
1 2 31 0 21 31
2 2 15 6 14 9
3 6 21 1 11 46
4 5 21 0 14 34
5 6 31 6 20 34
6 0 26 2 18 30
7 6 38 7 29 25
8 6 35 1 17 53
9 7 68 5 43 37Grand Mean
± 1 S.D. (n = 27) 4 ± 3 32 ± 16 3 ± 3 21 ± 10 34%Range (n =
27) 0 - 13 9 - 72 0 - 8 10 - 53 9 - 53
95% C.I. 3.2 – 5.7 25.6 – 37.9 2.1 – 4.3 16.7 – 24.8
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Specimen No. NeutralMaximallyPronated Neutral
MaximallyPronated
HyProCure% Reduction
foot after
HyProCure n = 3 for each reported data value1 2 27 1 20 262 3 25 5 14 433 1 26 1 14 454 1 16 2 7 575 1 25 2 21 166 1 28 0 19 337 2 32 2 19 428 2 15 2 7 549 5 64 7 44 31
Grand Mean ± 1 S.D. (n =
27) 2 ± 2 29 ± 15 2 ± 2 18 ± 11 38%
Range (n = 27) 0 - 7 10 - 73 0 - 7 5 - 51 16 - 5795% C.I. 1.4 - 2.7 23.0 - 34.5 1.6 - 3.3 14 - 22.8
Porta Pedis Study
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Overall Results
29 1832 21
34% reduction- Tarsal tunnel38% reduction- Porta pedis
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Part II Findings
Strain on the Tibialis Posterior Nerve
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Stay Tuned-
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Why Posterior Tibial Nerve Involvement
• Increased Pressures within both the tarsal tunnel and porta pedis
• Flattening forces acting on the nerve(s)• Strain/elongation forces placed on nerve(s)• Intraneural damage• Vascular impairment within the nerve• Repetitive Trauma to the nerve fibers
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Thoughts
• Patients present with a wide variety of medical backgrounds
• Short/Long-term results of pure decompression*?
• What is the missing piece to the puzzle?• External modalities are less than optimal• Internal stabilization is preferred
*Chaudhry V, Russell J, Belzberg A. Decompressive surgery of lower limbs for symmetrical diabetic peripheral neuropathy. Cochrane Database of Systematic Reviews 2008, Issue 3. Art. No.: CD006152. DOI: 10.1002/14651858.CD006152.pub2.
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Next Step-Suggestions
• Early presentation- internal stabilization with HyProCure as a stand-alone procedure
• Significant symptoms- combined neurolysis decompression along with HyProCure
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EBM-HyProCure
• 5 year retrospective study- 6% removal rate as a stand alone procedure
• Effect of HyProCure on Navicular Drop• Prospective Outcome Study soon to be
submitted for publication• The findings of this study will be published in 2
parts in Journal of Foot & Ankle Surgery 1st part should be in the Jan/Feb issue 2011.
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QuestionsThank You