Magnetic resonance imaging techniques demonstrate soft tissue damage in the diabetic foot

Brash, PD; Foster, John E.; Vennart, W.; Anthony, PP; Tooke, JE

doi:10.1046/j.1464-5491.1999.00005.x

Cited by 76 publications

(54 citation statements)

References 14 publications

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“…This clearly indicates that determination of muscle mass reflects motor function. In healthy subjects, r values between muscle strength and total muscle volume exceeded 0.85, a slightly closer relation than the one between muscle cross-sectional area and muscle strength (4).…”

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confidence: 65%

“…In a series of experiments in long-term diabetic patients, we have observed that muscle weakness in the lowerleg muscles occurs to a substantial degree in chronic neuropathic patients, closely related to muscle atrophy, whereas nonneuropathic patients have normal muscle strength and striated muscle mass (3). In the more distally situated intrinsic foot muscles, Brash et al (4) observed atrophy in neuropathic diabetic patients using a specific magnetic resonance imaging (MRI) contrast sequence; however, the atrophy was not quantified. Since diabetic polyneuropathy shows a centripetal pattern of progression, quantification of the more distally situated foot muscles could possibly serve as an early marker for motor dysfunction in diabetic neuropathy.…”

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confidence: 96%

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Atrophy of Foot Muscles

2004

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OBJECTIVE -Diabetic neuropathy is a length-dependent process that leads to reduced muscle strength and atrophy of leg muscles in some patients. We hypothesized that intrinsic foot muscles are atrophied in diabetic neuropathy and that the degree of atrophy is a measure of motor dysfunction closely related to the neuropathic process.RESEARCH DESIGN AND METHODS -Consecutive cross-sectional magnetic resonance images of the nondominant foot were obtained for stereological determination of the total volume of the intrinsic foot muscles (VFM) in 23 long-term diabetic patients with (n ϭ 15) and without (n ϭ 8) chronic neuropathy and in 23 matched healthy nondiabetic control subjects. Based on clinical examination, nerve conduction studies, and quantitative sensory examination, a neuropathy rank-sum score was calculated for each patient.RESULTS -Total VFM was 86 Ϯ 52, 165 Ϯ 34, and 168 Ϯ 42 cm 3 in neuropathic patients, nonneuropathic patients, and healthy control subjects, respectively (P Ͻ 0.001). There was a close inverse relationship between the neuropathy rank-sum score and the VFM (r ϭ Ϫ0.75, P Ͻ 1 ϫ 10 Ϫ5 ).CONCLUSIONS -Total volume of the foot muscles is halved in patients with diabetic neuropathy. Atrophy of foot muscles is closely related to the severity of neuropathy and reflects motor dysfunction. Diabetes Care 27:2392-2385, 2004L oss of ankle jerks and of sensation in the feet are early clinical signs of chronic polyneuropathy in diabetes. In contrast, motor weakness with loss of the ability to stand on the heels occurs late in the clinical course and only in a minority of diabetic patients. Previous studies on motor function in diabetic neuropathy have relied on simple clinical tests such as the ability to stand on heels (1) and neurophysiological examinations of motor nerves (2). In a series of experiments in long-term diabetic patients, we have observed that muscle weakness in the lowerleg muscles occurs to a substantial degree in chronic neuropathic patients, closely related to muscle atrophy, whereas nonneuropathic patients have normal muscle strength and striated muscle mass (3). In the more distally situated intrinsic foot muscles, Brash et al. (4) observed atrophy in neuropathic diabetic patients using a specific magnetic resonance imaging (MRI) contrast sequence; however, the atrophy was not quantified. Since diabetic polyneuropathy shows a centripetal pattern of progression, quantification of the more distally situated foot muscles could possibly serve as an early marker for motor dysfunction in diabetic neuropathy.We hypothesized that muscular atrophy is an integral part of diabetic neuropathy that is easily detected in the feet and is closely related to the severity of neuropathy. In the present study, foot muscle volume was studied in a group of longterm diabetic patients with and without neuropathy and in a group of nondiabetic control subjects.RESEARCH DESIGN AND METHODS -Twenty-three type 1 diabetic patients (16 men and 7 women) aged 46 years (median, range 27-62) with a median diabetes durat...

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Atrophy of Foot Muscles

2004

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“…These injuries cause stiffening of the plantar fat pad, which normally cushions the repeated pressures during ambulation. Brash et al (23) found nonspecific fibrosis of the plantar fat pad in diabetic patients with neuropathy. They hypothesized that the factors responsible for the maintenance of normal fat pad include neurological, vascular, and hormonal influences.…”

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confidence: 99%

Soft tissue enhancement on time‐resolved peripheral magnetic resonance angiography

Zhang

Kent

Bush

et al. 2004

Magnetic Resonance Imaging

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Purpose: To evaluate the incidence and locations of soft tissue enhancement on time-resolved two-dimensional projection magnetic resonance angiography (MRA) of the calf and foot. Materials and Methods:Time-resolved two-dimensional projection MRA of the knee, calf, and foot, performed at 1.5 Tesla using the head coil, was retrospectively reviewed in 326 patients. Soft tissue enhancement of the foot was identified and graded by blinded review. Subsequently, patient medical records were reviewed to determine the presence or absence of diabetes, cellulitis, gangrene, and ulceration of the foot and presence of neuropathic joints.Results: Enhancing spots were identified in 228 patients. For those feet without clinical abnormalities, diabetic patients had an average of 1.2 enhancing spots per foot, while nondiabetics had only 0.6 (P Ͻ 0.001). Higher-grade lesions were more prevalent in diabetics and in heavier patients. Of 64 patients with follow-up, 8 (13%) developed cellulitis (N ϭ 4) or ulceration (N ϭ 4) at the location of an enhancing spot, including 5 diabetic and 3 nondiabetic patients. Conclusion:Pedal soft tissue enhancement frequently occurs on time-resolved gadolinium (Gd):MRA of the feet. The etiology is uncertain, but the high frequency in diabetic patients and observation of progression to cellulitis/ulceration suggest this soft tissue enhancement may identify sites of subclinical pedal soft tissue injury.

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“…The weighted kappa was 0.94, which shows very good intraobserver agreement (13). Remarkable degrees of intrinsic muscle atrophy have been observed in patients with long-standing diabetes and peripheral neuropathy, and were suggested in previous studies to play a significant role in altered gait biomechanics (7,10,11). In those studies, intrinsic muscle atrophy was assessed quantitatively with the use of special MRI sequences.…”

Section: Discussionmentioning

confidence: 99%

“…Because of its multiplanar imaging capability and inherent superiority in tissue contrast, magnetic resonance imaging (MRI) is increasingly being used as a tool to assess structural pathology in the foot or lower leg of diabetic patients with peripheral neuropathy (5,(7)(8)(9)(10)(11). These assessments are considered important for improving our understanding of the relationship between structure and function in the foot and the pathogenesis of foot ulceration.…”

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Reproducibility of foot structure measurements in neuropathic diabetic patients using magnetic resonance imaging

Bus

Maas

Lindeboom

2006

Magnetic Resonance Imaging

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Purpose:To assess the intra-and interobserver agreement of commonly reported foot structure measurements in diabetic patients with neuropathy using magnetic resonance imaging (MRI). Materials and Methods:In 23 neuropathic diabetic patients and five age-matched healthy controls, sagittal-plane MR images of the forefoot were obtained to assess joint configuration and plantar fat-pad thickness on two different occasions by the same observer and once by a different observer. The degree of intrinsic muscle atrophy was scored from coronal plane images on two different occasions by two observers. Results:The intraclass correlation coefficients (ICCs) between occasions and between observers were Ͼ0.94. The mean differences (bias) and the limits of agreement (LoA ϭ mean Ϯ 2 SDs) were small for the metatarsal-phalangeal (MTP) joint angle, toe angle, and plantar fat-pad thickness (bias Յ 0.8°or 0.2 mm, LoA Յ 3.8°or 0.8 mm), but larger for interphalangeal joint angles (bias Յ 3.4°, LoA Յ 8.8°). The weighted kappa for intrinsic muscle atrophy was 0.94. Conclusion:Static foot structure data can be assessed reliably using MRI. Because changes in foot structure contribute to the development of foot ulcers in neuropathic patients, MRI may be a useful technique to assess risk of ulceration in these patients. DIABETIC FOOT ULCERATION is a frequently reported and serious complication in people with diabetes and peripheral neuropathy, and precedes the vast majority (85%) of lower-extremity amputations (1). Elevated dynamic plantar pressure has been established as a major risk factor for plantar ulceration in the diabetic foot with lack of protective sensation (2).Structural changes and deformities of the foot, such as claw/hammer toe deformity and thinning of soft tissue or fat pads underneath the metatarsal heads, are associated with increased plantar pressures in diabetic subjects (3-6). Additionally, intrinsic muscle atrophy secondary to peripheral neuropathy may significantly affect foot function and lead to altered gait biomechanics (7).Because of its multiplanar imaging capability and inherent superiority in tissue contrast, magnetic resonance imaging (MRI) is increasingly being used as a tool to assess structural pathology in the foot or lower leg of diabetic patients with peripheral neuropathy (5,7-11). These assessments are considered important for improving our understanding of the relationship between structure and function in the foot and the pathogenesis of foot ulceration.However, little is known about the reproducibility of the MRI assessments for this purpose. Therefore, the purpose of this study was to evaluate the intra-and interobserver agreement of (semi-)quantitative measurements by MRI of foot structure in neuropathic diabetic patients. MATERIALS AND METHODS SubjectsTwenty-eight subjects participated in this study and underwent MRI of the foot. The study group consisted of 23 diabetic patients with peripheral sensory neuropathy (15 men and eight women, mean age ϭ 56.8 years) and five age-matched healthy subject...

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Magnetic resonance imaging techniques demonstrate soft tissue damage in the diabetic foot

Abstract: Changes in MT activity reflect qualitative structural changes which this study reveals are extensive in the diabetic neuropathic foot. Fibrotic atrophy of the plantar fat pad may affect its ability to dissipate the increased weight-bearing forces associated with diabetic neuropathy.

Cited by 76 publications

References 14 publications

Atrophy of Foot Muscles

Atrophy of Foot Muscles

Soft tissue enhancement on time‐resolved peripheral magnetic resonance angiography

Reproducibility of foot structure measurements in neuropathic diabetic patients using magnetic resonance imaging

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