An investigation into the hammer toe effects on the lower extremity mechanics and plantar fascia tension: A case for a vicious cycle and progressive damage.

doi:10.21203/rs.3.rs-1758484/v1

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An investigation into the hammer toe effects on the lower extremity mechanics and plantar fascia tension: A case for a vicious cycle and progressive damage.

https://doi.org/10.21203/rs.3.rs-1758484/v1

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Predicting and being aware of the side effects of the damage in one limb on the performance of other limbs is very important in the prevention of progressive damages. Finite element (FE) and musculoskeletal modeling can be helpful in this way. Hence, the aim of this study is to investigate the side effects of the hammer toe deformity on the lower extremity, especially on the plantar fascia functions. To compare the joint reactions of the hammer toe and healthy foot (HF), two musculoskeletal models (MSM) of the healthy and the hammer toe foot (HTF) subject were developed based on gait analysis. A previously validated 3D finite element model was constructed using Magnetic Resonance Imaging (MRI) of the diabetic participant with the hammer toe deformity processed at five different events during the stance phase of gait.

It was found that the hammer toe deformity makes dorsiflexion of the toes, and the windlass mechanism is less effective during walking. Specifically, the FE analysis results showed that plantar fascia (PF) in HTF compared to HF played a less dominant role in load bearing with both medial and lateral parts loaded. Also, the results indicated that the stored elastic energy in PF was less in HTF than the HF, which can indicate a metabolic cost during walking. Internal stress distribution shows that the majority of ground reaction forces are transmitted through the lateral metatarsals in hammer toe foot, and the probability of fifth metatarsal fracture and also progressive deformity like tailor's bunion was subsequently increased. The MSM results showed that the joint reaction forces and moments in hammer toe foot have deviated from normal function, with the metatarsophalangeal joint showing that the reactions in hammer toe are less than the healthy foot. This can indicate a viscous cycle of foot deformity, increased internal stresses, change in muscle forces and joint kinetics and plantar fascia tensile forces from normal, which can lead to increase the risk of ulceration in the diabetic foot.

Plantar fascia

Hammer toe

Finite element analysis

Plantar soft tissue

Diabetic foot ulcer

The human body is a complicated mechanism with so many components that an operational issue in one section might impact the other and potentially cause the entire mechanism to deteriorate. Lower extremity health is a critical aspect of overall life quality that is influenced by various factors, including age, weight, musculoskeletal disorders, daily activities, and footwear [1–6]. Some of the techniques that can be used to obtain appropriate information about the various internal tissues and elements functions are musculoskeletal and finite element modeling[7–9], gait analysis [10, 11], and in-Vivo tests [12–15]. These techniques’ data cause better identification of biomechanical body parameters, especially in the lower extremity.

The health of the limbs has long been a priority and should be more accurate for diabetics to avoid injury, particularly on the foot area. Diabetic ulceration has been widely studied in previous researches [16–19], which shows that this issue is more important for diabetics. Excessive mechanical forces are one of the causes of foot ulcers [20, 21]. Foot deformities can change the force distribution in components of the foot such as the plantar and bones and also can be the starting point for progressive damage such as foot ulcers [22–24]. Some injuries and damages in one area cause problems in another. Various studies have been conducted to see whether damage and deformity in one part of the foot might lead to harm in other sections of the body, such as the ankle, knee, and hip. The effect of flat feet [25–27], hallux [28, 29], and foot arch[30–32] on other portions of the lower limb are among them. The plantar fascia and joints are the significant elements of the locomotor organs. Forces and moments of the joints have been regarded in several types of researches as the factors that may be studied in joints [33–38].

PF function and pathologies were considered in previous studies [39, 40]. The plantar fascia is a thick band of connective tissue that crosses the bottom of the foot, extending from the calcaneus to the base of the toes. PF plays important roles in foot arch support, stress distribution (load-sharing), energy storage and shock absorption during walking [41]. As mentioned in several studies, plantar fascia stores elastic energy during the first half of the stance phase and some portion of this stored energy returns to the foot during the longitudinal arch recoiling at the late stance phase which brings a part of the mechanical energy required for each step and enhancing propulsion [42, 43]. Stretched plantar fascia adds stiffness to the medial and lateral arch and makes a situation to increase the arch height whereby the foot muscles (soleus, medial and lateral gastrocnemius) can create a high plantarflexion moment in order to propel the body forward [44, 45] and this issue will be reinforced by windlass mechanism. The windlass mechanism is based on the shortening of the plantar fascia due to hallux dorsiflexion [46, 47].

The hammer toe is one of the foot deformities. The area involved in this deformity is the proximal interphalangeal joint, bent downward, and the toes deviate from being aligned to the metatarsals in rest and unloading situations. This abnormality occurs with a probability between 2 and 20% of the toe deformities [48]. Despite various reports about the association of some foot deformities with subsequent damages in the foot, ankle, knee, and hip, there has not been a full investigation of the effect of hammer toe deformity on the joints, PF, and overall progressive detriment. The aim of this study is to indicate some of the hammer toe side effects on the lower limb, especially in PF, during walking using finite element and musculoskeletal modeling.

2.1 Subjects

First participant was a male (age: 53, height: 165 cm, weight:93 Kg) with hammer toes deformity in the left foot and healthy contralateral foot (right foot). Second participant was healthy female (age: 25, height: 163 cm, weight:58 Kg) with no foot abnormalities volunteered for the study. They were recruited for gait analysis, and MRI imaging was done only on the male subject's left foot.

2.2 Gait analysis

Three-dimensional gait analysis was taken on both participants. 24 markers based on Vicon plug-in gait placement recommendations [49] and 14 extra markers as a modified plug-in gait were used [50–53]. The laboratory was equipped with 10 infrared cameras motion capture system (Vicon, Oxford, UK) with data collection speed at 100 Hz. For collecting ground reaction forces (GRFs) and centre of pressure (COP), two force plates (Kistler, Winterthur, Switzerland) were occupied at 100 Hz sampling. For collecting the foot plantar pressure distribution, one pressure pad system (Payatek, Tehran, Iran) was employed. The electromyography (EMG) system was a 6-channel wireless Myon product (Schwarzenberg, Switzerland) located in line with SENIAM guidelines [54, 55]. Nexus software (Vicon, Oxford, UK) was responsible for collecting Kinematic data (marker trajectories), muscle activation signals, GRFs, and COP in synchronization. Muscles Activation were obtained from six major muscles: lateral gastrocnemius, tibialis anterior, soleus, medial gastrocnemius, tibialis posterior, and peroneus longus. In order to use the EMG’s data, a five-step procedure consisting of some filters and math operations were used, as mentioned in the previous study [56]. Both participants were required to walk barefoot across the walkway at a normal speed. In addition to the dynamic trials repeated several times to ensure repeatability of gait analysis results, the static trial was collected.

2.3 Musculoskeletal modeling

The 'gait 2392' generic musculoskeletal model in OpenSim software was scaled using static trial data and the participant's body mass [57]. This general model consists of 92 musculotendon actuators, 10 rigid bodies with 23 degrees of freedom (DOF) was utilized for predicting joint reaction forces (JRFs) and muscle forces. After scaling, the inverse kinematic tool was used to reconstruct desired walking motion. Net moments and muscle forces were calculated using inverse dynamic and static optimization tools, respectively. The reactions between two contacting segments of the joints were determined using the Joint Reaction Analysis in OpenSim, which performs as a post-processor step whose input includes GRFs, muscle forces, and the output of the inverse kinematic. All of this input will be induced on the free body diagram of the scaled model segments for calculating the joint reactions [37, 58, 59]. The musculoskeletal model for the participant with hammer toe foot was validated in our previous study [60]. In order to validate the healthy participant model, muscle activation results in OpenSim software were compared to filtered and normalized similar signals of the EMG test. Comparing the pattern of the muscle activations shows a good agreement. Tibialis anterior and medial gastrocnemius muscle activations can be seen in Fig. A1 at appendix A.

The Mimics software (Materialise, Leuven, Belgium) was used to segment and generate a 3D soft and hard tissue model of the participant's left foot with hammer toe based on MRI medical images. A 1.5 T MRI scan (Philips Ingenia, spacing between slices: 0.5 mm and slice thickness: 1 mm, sequence 3D mDion Te Hr, TE/TR 9/29) was performed on the left foot in an unloaded position. Pads and cushions kept the leg and foot at a 90 degree angle. The model had 30 bones (medial and lateral sesamoids, 14 phalanges, 5 metatarsals, cuboid, 3 cuneiforms, navicular, calcaneus, talus, and the distal sections of the tibia and fibula) and a bulk of soft tissue. 74 cartilage layers for 37 pairs of joints were incorporated to increase the model's accuracy. Surface-to-surface frictionless contact was used to describe the interaction between cartilage layers.

To perform the finite element analysis, all components were imported into ABAQUS software (SIMULIA, Providence, USA). The ligaments are not clearly defined in MRI scans. So, 2174 truss elements were added to the model to identify key ligaments and the plantar fascia which were placed using anatomical atlases [61]. Achilles tendon tied on top of the calcaneus (see fig. 1). soft tissue encased all of the other components by embedding the bones, cartilages, ligaments, and Achilles tendon in to the bulk of the soft tissue. The ground was represented by a 3D rigid rectangular plate. Based on previous research, contact between the plate and the sole of the foot was regarded surface to surface with a frictional coefficient of 0.6 [62]. According to the literature, the material properties of all components were considered to be as shown in Table 1 [63, 64].

3.1 Walking simulation:

Under quasi-static analysis, five instants (heel strike, early stance, midstance, late stance, and toe-off) of a stance phase throughout the gait cycle were performed. The GRFs and muscle forces were applied to the model at each event. During the analysis, the top surface of the soft tissue, distal tibia, and fibula were fixed as boundary conditions. GRFs were applied to the ground plate at COP. The proper placement of COP on the model was determined according to the relative location of anatomical landmarks and COP. Six muscle forces were applied to the model. The forces of the soleus, medial, and lateral gastrocnemius were applied to the Achilles tendon, and the force of the tibialis anterior, tibialis posterior, and peroneus longus, were allocated to their relevant bones along the muscle force vectors defined by the OpenSim model. [8, 65].

Comparison between the results of the plantar fascia tension force during walking obtained by finite element (FE) modeling of HTF in the current study, Chen et al. [66], and Erdemir et al. [41] are shown in Fig. 2. Muscle forces obtained by Opensim for major active muscle in the propulsion of walking are shown in Fig. 3. As mentioned in section 3, FE modeling only was performed for the left hammer toe foot. Figure 4 shows the results of lateral/medial displacement of forefoot bones during the four events of stance phase predicted by finite element modeling. The results of the stress distribution in bony structure and also plantar and internal von Mises stress distribution in sagittal plane view are shown in the Fig. 5. It should be noted that the FE model was previously validated by comparing the predicted plantar pressure and the pressure pad results [60].

Results of plantar fascia stresses are shown in Fig. 6. After presenting the results in the sole, the question is whether changes in the location of the COP and the areas involved in weight-bearing due to hammer toe could affect the performance of other parts, such as the joints. For this aim, the results of the foot joint reactions during the walking are presented in Figs. 7 and Appendix B for two participants, healthy and hammer toe foot. Forces and moments direction are based on coordinate shown in Fig. 1.

Table 1

material property of the all parts [63, 64] and element type of the components
Components	Young’s modulus (MPa)	Poisson’s ratio	Cross section (mm²)	Element Type
Hard tissue (bones)	7300	0.3	--	Tetrahedral
Ligament	260	--	18.4	Truss
Cartilage	1	0.4	--	Tetrahedral
Plantar fascia	350	--	290.7	Truss
Ground support	17000	0.1	--	Linear hexahedral
Achilles tendon	816	3.0	--	Tetrahedral
Encapsulated soft tissue	Hyperelastic (second-order polynomial strain energy potential equation, C₁₀ = 0.08556 Nmm^− 2,C₀₁ = -0.05841 Nmm^− 2, C₂₀ = 0.03900 Nmm^− 2, C₁₁ = -0.02319 Nmm^− 2, C₀₂ = 0.00851 Nmm^− 2,D₁ = 3.65273 mm²N^− 1, D₂ = 0.0000 mm²N^− 1)			Tetrahedral

The hammer toe is one of the relatively common deformities at the foot. Investigation of hammer toe side effects on the other parts of the lower limb can be helpful for better identification of this deformity as well as prevention of progressive pain. For this aim, the finite element model including soft and hard tissue, ligament, and cartilage were used as well as musculoskeletal modeling. The validation of the finite element results was performed by comparing the results of the predicted plantar pressure distribution of the foot with the results of the experimental pressure pad at previous study [60]. In order to validate musculoskeletal model, the results of the predicted intensity of muscle activities were compared with EMG signals.

As our previous study [60] and soft tissue von Mises stress distribution in Fig. 5 show, the presence of a hammer toe, not only causes the stress concentration in the forefoot, but also will increase plantar pressure and internal stresses and will increase the risk of injury and ulcers. In the present study, it is tried to show the other aspects of hammer toe deformity effects on the lower limb.

Wang et al. [67] showed that body weight force (BWF) transmits by the medial metatarsals (1st, 2nd, and 3rd toes and metatarsals), which is in line with the peak plantar pressure region in Akrami et al. [8] results. In addition, Kalra et al. [68] showed the important role of medial metatarsals, especially the second one in BWF transmission by investigating on 10 cadaveric feet. As shown in Fig. 5, the hammer toe changes the location of transfer body weight force line to the lateral side of the foot, and the 3rd, 4th, and 5th metatarsal had a significant function in weight-bearing. The function of several parts of the lower limb may be affected as a result of this condition. Previous researches on healthy feet found that fifth metatarsal has lower maximum stress compared to other metatarsals [67, 69, 70] while fifth metatarsal fractures are thought to occur more frequently than any other metatarsal fractures [71], while the hammertoe increased stress in the fifth metatarsal, indicating an increased risk of fifth metatarsal fracture. In Fig. 4, the results of lateral/medial displacement of hammer toe foot show that the displacement of the little toe, especially in the metatarsal region, is considerable and indicates expectancy and the probability of bunionette (tailor's bunion) as the subsequent possible deformity. At the same time, the results of the stress distribution, as well as the displacement of the first toe in the MTP joint, do not demonstrate the possibility of Bunions (Hallux Valgus), as a side effect of the hammer toe.

The contact area of the foot with the ground is reduced when the hammer toe occurs, and the toes are less involved in weight bearing during walking. As shown in Fig. 7, MTP joint reaction force for hammer toe foot is less than the healthy foot, and also the stress distribution results in Fig. 5 indicate the significant difference between metatarsals and toes stress, and this issue shows a shift in the contribution of the toes in weight bearing to the metatarsals. Furthermore, this means a reduction in foot length which acts flat spring-like. The stiffness of the flat spring rises as its length decreases, so the hammer toe exhibit more rigid foot, and this condition has an impact on the lower limb's induced forces. A rigid foot is less likely to be able to absorb shocks, resulting in intense ground forces being imposed on the foot [72, 73]. Rigid foot causes higher ankle, knee, and hip joint reaction forces, which in this study appeared in knee forces with 50% higher than a healthy foot and also disappearing the double hump in vertical knee and hip reaction forces that were monotonically increasing in most of the stance phase, as shown in figures B1 and B2 at appendix B.

The results of the joint reactions indicate the distinction of the knee abduction moment pattern, as well as the amount of force on the knee and hip between hammer toe and healthy foot as shown in Appendix A. Our results of the healthy foot (pattern and magnitude) are in line with previous studies [74, 75]. A notable point on the peak of the reaction moments is that since the hammer toe shifted the position of the COP to the lateral, the moment arm of the total GRFs has been reduced on joints, which is aligned with the previous finding [76]. For this reason, the peak reaction moments for hammer toe foot are lower than the healthy foot.

Based on the plantar fascia tension shown in Fig. 6, the productivity of plantar capacity does not occur in the hammer toe foot, and as a result, there is less shock and energy absorption in the plantar fascia of the hammer toe foot. Caravaggi et al. [77] showed that the overall tensional plantar fascia load decreases from medial to lateral in healthy foot and also the previous studies showed that the medial side of the plantar has higher stress during walking [78], and the medial side was reported as maximum stress area [44, 66] which show that hallux plantar ray has a significant role in elastic energy storage. On the other hand, plantar fasciitis occurs as a consequence of excess mechanical load on the fascia [79, 80]. Results of this study show that for the hammer toe as the deformity and consequent poor windlass mechanism, the maximum tensional load does not occur at the medial side of the plantar fascia, and the first ray of the plantar fascia under the 1st MTP has lower tensile force during walking shown in Fig. 6. Furthermore, the result of PF stresses shows as well as 2nd plantar ray, lateral side of the PF is expected to be more prone to the onset of small tears and injury in HTF as a result of the continues forces induced during the stance phase of gait. The need for more muscular forces will be reduced by storing energy in tendons and ligaments during walking [42, 81, 82] expected up to 17% of the overall mechanical energy spent during walking [83]. As shown in Fig. 3, due to reduction of the elastic stored energy at the PF, required power and muscle forces for HMT foot is higher than HF, and this issue raises metabolic cost. The soleus, medial and lateral gastrocnemius make a contribution to 93 percent of the plantar flexion torque during a step [84]. The tensions in the Achilles tendon and plantar fascia are mechanically connected. Increasing the PF tension, in addition to providing integrity to the bony arch structure, increases the tension in the Achilles tendon, which is likely to reduce the metabolic cost of walking [85]. As shown in Fig. 2, PF force significantly reduced in HMT foot, and as shown in Fig. 3, this issue demands extra soleus, medial and lateral gastrocnemius muscle force for effective propulsion and this matter makes the body use more energy during walking.

According to Zhang et al. [86], injuries in joints, such as the knee joint and osteoarthritis, will increase the force induced on foot. Also based on the results of soft tissue stress distribution shown in Fig. 5, deformity at the metatarsal head makes the stress concentration and increases internal and plantar stresses in hammer toe foot which is consistent with previous studies [22, 60].

The hammer toe deformity was found to change the pattern and line of bodyweight force transmission and also affects the forces and moments of the joints. Also, this study revealed that hammer toe deformity makes dorsiflexion of the toes and the windlass mechanism less effective during walking. Specifically, the FE results showed that plantar fascia (PF) in HTF played a less dominant role in bearing load in comparison with HF. Also, the results indicated that the stored elastic energy in PF was less in HTF compared to the HF, which can indicate a metabolic cost during walking. Stresses in the plantar fascia element for HTF shows not only the medial part but also the lateral part is exposed to plantar fasciitis. Internal stress distribution shows that the majority of bodyweight force is transmitted through the lateral metatarsals in hammer toe foot, and the probability of fifth metatarsal fracture and also progressive deformity like tailor's bunion was subsequently increased. The MSM results show the joint reaction forces and moments in the hammer toe foot have deviated from the normal function which the intensity of the metatarsophalangeal joint reactions in hammer toe are less than the healthy foot, HTF joint forces have a more extended period with monotonically increasing intensity during the stance phase in comparison to HF. In this way, a cycle can be indicated between five parameters: foot deformity, increased plantar pressure, stress concentration and increased internal stresses, change in body weight force transmission line, and deviation of joint reactions and plantar fascia from normal manner.

Consequently, it can be stated that a cycle between deformity, stress concentration and increased internal stresses, changes in BWF transmission line, joint malfunction and increased plantar pressures are established in hammer toe foot that can lead to an increase in the risk of ulceration for the diabetic foot (figure C1).

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An investigation into the hammer toe effects on the lower extremity mechanics and plantar fascia tension: A case for a vicious cycle and progressive damage.

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Abstract

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1. Introduction

2. Method

2.1 Subjects

2.2 Gait analysis

2.3 Musculoskeletal modeling

3. Finite element modeling

3.1 Walking simulation:

4. Result

5. Discussion

6. Conclusion

References

Additional Declarations

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