Relationship between talocrural joint mobility and venous ulcer

Abstracts

CONTEXTO: O presente estudo avalia a mobilidade da articulação talocrural nos seis estágios clínicos da classificação CEAP (clínica, etiológica, anatômica e patofisiológica do International Consensus Committee Reporting Standards on Venous Disease) para doença venosa utilizando a goniometria, e detecta redução da mobilidade articular nos estágios mais avançados da doença, C5 e C6 (úlcera cicatrizada ou ativa). OBJETIVO: Investigar a existência de uma relação entre a severidade clínica da doença venosa crônica dos membros inferiores e a diminuição do grau de mobilidade da articulação talocrural. MÉTODO: Selecionaram-se aleatoriamente 120 membros pertencentes a 88 pacientes brancas, que foram separados com base em sua apresentação clínica de acordo com a categoria C da classificação CEAP, sendo distribuídos em 6 grupos pertencentes às categorias de C0-C1 (grupo controle) até C6, com 20 membros cada um e médias de idade próximas para cada grupo. O grau de mobilidade do tornozelo foi acessado por goniometria de apoio plantar em posição de decúbito supino. RESULTADOS: Os grupos C de CEAP apresentam diferença significativa em relação ao grau de mobilidade da articulação talocrural medida por goniometria (p < 0,001). C6 difere significativamente dos demais grupos (p < 0,05); C5 difere significativamente de C6, C3, C2 e C0-C1 (p < 0,05), mas não apresenta diferença significativa do grupo C4; C4 difere significativamente do grupo C6 (p < 0,05) e não difere dos demais grupos; C0-C1, C2 e C3 não apresentam diferença significativa entre si e em relação a C4, e diferem dos grupos C5 e C6 (p < 0,05). O nível de significância utilizado para os testes foi de 5%. CONCLUSÃO: Existe relação entre a severidade clínica da insuficiência venosa crônica dos membros inferiores e a diminuição do grau de mobilidade da articulação talocrural, e ela se faz mais evidente na presença de úlcera venosa ativa ou cicatrizada.

Insuficiência venosa; articulação talocrural; úlcera venosa

ORIGINAL ARTICLE

Relationship between talocrural joint mobility and venous ulcer

Cleusa Ema Quilici Belczak^I; Gildo Cavalheri Jr.^II; José Maria Pereira de Godoy^III; Roberto Augusto Caffaro^IV; Sergio Quilici Belczak^V

^IPhD student in General Surgery, Faculdade de Ciências Médicas, Santa Casa de São Paulo, São Paulo, SP, Brazil. Professor, Graduate Program in Lymphovenous Rehabilitation, Faculdade de Medicina de São José do Rio Preto (FAMERP), São José do Rio Preto, SP, Brazil

^IIPhysical therapist. MSc. in Health Sciences, FAMERP, São José do Rio Preto, SP, Brazil

^IIIPhysician, professor. Associate professor, Cardiology and Cardiovascular Surgery, Department of Surgery, FAMERP, São José do Rio Preto, SP, Brazil. Researcher, Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

^IVPhysician. Associate professor, Vascular Surgery, Department of Surgery, Faculdade de Ciências Médicas, Santa Casa de São Paulo, São Paulo, SP, Brazil

^VResident, Vascular Surgery, Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo, SP, Brazil

^{Correspondence}

ABSTRACT

BACKGROUND: This study assesses talocrural joint mobility considering the six stages of CEAP classification (clinical, etiologic, anatomic and pathophysiologic by the International Consensus Committee reporting standards on venous disease) for venous disease using goniometry, and detects reduction in joint mobility in more advanced stages of the disease, C5 and C6 (healed or active ulcer).

OBJECTIVE: Investigate the existence of a relationship between clinical severity of chronic venous disease of the lower limbs and reduction in talocrural joint mobility.

METHODS: A total of 120 limbs from 88 Caucasian patients were randomly selected. They were divided based on clinical presentation according to the C clinical category of CEAP, being distributed into six groups belonging to categories from C0-C1 (control group) to C6, with 20 limbs each and similar mean age for each group. Range of ankle mobility was assessed by goniometry in the supine position.

RESULTS: C groups on the CEAP classification showed significant difference in relation to talocrural joint mobility measured by goniometry (p < 0.001). C6 was significantly different from the other groups (p < 0.05); C5 was significantly different from C6, C3, C2 and C0-C1 (p < 0.05), but with no significant difference from C4; C4 was significantly different from C6 (p < 0.05) and not different from the other groups; C0-C1, C2 and C3 were not significantly different between themselves and in relation to C4, but were different from C5 and C6 (p < 0.05). Significance level used for tests was 5%.

CONCLUSION: There is a relationship between clinical severity of chronic venous insufficiency of the lower limbs and reduction in talocrural joint mobility, which is more evident in the presence of active or healed venous ulcer.

Keywords: Venous insufficiency, talocrural joint, venous ulcer.

Introduction

Chronic venous insufficiency (CVI) of the lower limbs is a cause of disability and embarrassment for affected individuals, besides representing a major socioeconomic problem in contemporary civilization. In its most severe forms, as in venous stasis ulcer, which is the last expression of this disease, it may lead to disability and be responsible for high public expenses. Comprehensive evaluation and proper therapeutic management of these patients is still far from ideal. Therefore, its enhancement is a great necessity in everyday angiographic practice.

It is known that the hemodynamics of lower limb venous return is complex, misunderstood and multifactorial.¹ Increased outpatient venous pressure (OVP) in patients with chronic arterial diseases has been well documented;^2-4 however, other parameters pertinent to deterioration of venous hemodynamics have not been properly valued and are little studied or cited. Venous diseases are a consequence of obstruction and/or reflux with or without calf muscle pump (CMP) dysfunction,^5,6 which is known to suffer direct influence of talocrural mobility.^7-9 CMP deficiency in limbs with active ulcer is a determining factor of prognosis severity.

This study aims at investigating the existence of a linear relationship between presence of venous stasis ulcer and limitation of talocrural joint mobility measured by goniometry.

Methods

A total of 120 limbs were randomly assessed in 88 adult Caucasian women seeking treatment for CVI of the lower limbs at Centro Vascular João Belczak, in Maringá (PR, Brazil). The limbs were at the left or right side and were clinically selected and classified according to the consensus issued by the International Consensus Committee on Venous Disease, called CEAP classification (in which C = clinical, E = etiologic, A = anatomic and P = pathophysiologic), which resulted in six groups with 20 limbs each, ranging from C0-C1 to C6. C0-C1 was considered the control group, since it is equivalent to absence of signs and symptoms or to presence of telangiectasias alone; C2 varicose veins; C3 edema; C4 skin changes (pigmentation, varicose eczema, lipodermatosclerosis); C5 healed ulcer and C6 active ulcer.¹⁰ All participants were part of the same urban population group and signed a consent term after being informed about the study objective, which had been submitted for appraisal and further approval by an ethics committee at a private university (CESUMAR).

Exclusion criteria were male individuals or those who were not Caucasian, as well as elderly individuals. Other criteria for exclusion were patients with ischemia, hypertension, diabetes¹¹ and/or those who were taking drugs that could interfere with formation of edema, such as diuretics and hormones, and patients with systemic lower limb edema, such as congestive heart failure, renal and hepatic failure, myxedema and traumatic or rheumatic joint diseases.

The patients were submitted to goniometry of the talocrural joint, referred to as ROAM (range of ankle motion) in the literature, whose value is equivalent to adding plantar and dorsal flexion. Measurement was performed with the patient in a supine position, always by the same physical therapist,¹² in a single measurement in the morning, using a portable goniometer with plantar support (which prevents interference from other foot joints) and is composed of two articulated metal blades (Figure 1), with an interposed sheet of paper where the angle was drawn and the value was calculated with a simple protractor.

Results

The table above shows that CEAP groups have a significant difference as to degree of talocrural joint mobility measured by goniometry (p < 0.001).

Using Bonferroni's multiple comparison test, we noted that group C6 was significantly different from the other groups (p < 0.05). Group C5 was significantly different from groups C6, C3, C2 and C0-C1 (p < 0.05), but had no significant difference compared with group C4, which was significantly different from group C6 (p < 0.05) and was not different from the other groups. Groups C0-C1, C2 and C3 were not significantly different between themselves and in relation to C4, but were different from groups C5 and C6 (p < 0.05) (Figure 2).

Table 3 and Figure 3 show that the groups characterized by CEAP classification were not significantly different in relation to age (p = 0.559).

Statistical analysis

All variables were initially analyzed descriptively. For quantitative variables, such analysis was performed by observing minimum and maximum values and calculating means, standard deviations and medians. To analyze hypothesis of equality of means between groups, analysis of factor variance was used with multiple comparisons by Bonferroni's test.¹³ Significance level for tests was set in 5%.

Discussion

Talocrural joint mobility along with venous valve competence working simultaneously is the engine that pumps venous blood return to the heart through anatomical relationships between nerves, muscles, tendons, capsule, ligaments and cartilages.⁷ It has been observed that reduced ROAM is an aggravating factor of CVI of the lower limbs, since total and permanent ankle ankylosis prevents patients from being healed by limiting or even canceling the most important action of the lower limb pump, which is the calf muscle pump.¹⁴

Loettzke, in 1956,¹⁵ described that the deep layer of crural fascia is closely related to Achilles tendon, which is pulled back by plantar flexion and forward by dorsal flexion during walking, defining that this traction causes a contraction of triceps surae, whose complete activation is only achieved by proper joint movements.¹⁶

Krämer & Gudat¹⁶ were the first to introduce the talocrural angle to provide an accurate measure of ankle mobility, using it not only to increase the knowledge on CVI pathophysiology and other diseases, but also to plan more comprehensive treatments.

Schmeller, in 1990,¹⁷ demonstrated that if the talocrural or tibiotarsal movement is inhibited during walking by presence of high heels or by muscle stiffness, whatever its etiology, efficiency of the 'ankle pump', as called by Bolliger & Borgnis in 1970,¹⁸ is compromised and consequently so is venous return.

According to studies carried out by Roaas & Andersson,¹⁹ normal adult men in a supine position have in average a total of 55-66 degrees of ROAM. They observed that there is no statistically significant difference between ankle mobility in the left or right side. Therefore, in our research, we selected limbs regardless of side.

Oppel, in Germany in 1987,²⁰ besides finding differences between racial groups (German and Japanese), verified higher mobility in women than in men and noted that, throughout the years, such difference was inexistent. These data were confirmed by Nigg et al. in 1992.²¹ Grimston et al.²² confirmed that ROAM is 15% lower during the eighth decade of life when compared with the third. In both genders, active muscle forces responsible for movements diminish as age increases, since ligaments and capsule stiffen, and cartilage changes, reducing movements. Based on these findings, we excluded from our study male individuals, elderly women (Table 2) and/or those who belonged to another racial group other than Caucasian, since these characteristics may interfere with the results.

The association of venous ulcer, the most severe complication of CVI of the lower limbs, and limitation of the talocrural joint was observed for the first time in 1931 by Dickson Wright.²³ Later, Ruckley²⁴ demonstrated, in 1982, in a study including 827 patients with ulcer, that 32% had severe limitation of ankle movement, of which only 9% had rheumatoid arthritis. In our sample, there was lower mobility exactly in C6 (active ulcer).

According to Tiernay et al.,²⁵ a major venous dysfunction is present only 5 days after an acute, stabilized ankle fracture and takes 18 days to heal. Timi et al.²⁶ carried out a comparative study of talocrural mobility measured by goniometry with plantar support in three groups of patients classified according to CEAP into C0, C3 and C4, including a total of 120 limbs, and found, by comparing C3 and C4, a difference of 36% between means, and only 11% between C3 and C0. Therefore, they concluded that patients classified as C4 are associated with a lower ROAM than C3 and C0 patients. They deduced that the difference between patients was particularly due to presence of ulcerations. In our sample, C4 patients (those with ulcerations) only differed statistically from C6, but not from the other groups.

Christopoulos et al., in 1989,⁵ studying the etiology of venous stasis ulcer, stressed CMP responsibility in the process by verifying that a good ejection fraction measured by air plethysmography, even in the presence of major reflux, there was no formation of ulcer, whereas with minor reflux and low ejection fraction, such complication could be present.

Back et al., in 1995,⁷ stressed that talocrural ankylosis starts 'before' the occurrence of ulcer, and verified that limbs with CVI have a ROAM that diminishes as severity of clinical symptoms of the disease increases. Those with active or healed ulcer have a significantly lower mobility than those without ulcer, which was also found in our study.

Dix et al.⁸ verified that limbs with varied venous diseases, from simple varicosities to ulceration, are associated with venous hypertension and talocrural limitation. In their sample, even C2 patients presented reduced ankle flexibility, which differs from our group.

ROAM reduction as clinical severity increases suggests that venous hypertension is one of the causes of such limitation. It is worth stressing that from C3 on there is edema and that this fact certainly also contributes to reduce ankle joint flexibility, creating a vicious cycle.

A limiting factor in our research was ROAM measurement performed in a supine position. The ideal is to perform it during ambulation using body weight to obtain an assessment with the function as close to normal as possible. On the other hand, the fact that C5 and C6 patients usually use long-term elastic compression can also be a determining factor of a slight ankle atrophy. In CVI of the lower limbs there may be intense pain, which, in its turn, may cause joint stiffness of varied degrees and even irreversible (Figure 4), promoting a secondary shortening of the Achilles tendon that results in a deformity in fixed plantar flexion, which may worsen prognosis and collaborate to a vicious cycle.²⁷

Based on the importance of this theme, on obtained data and considering the literature, we suggest that, besides physical examination in patients with severe venous diseases, ankle goniometry should also be performed. It is a simple, low-cost and repeatable method, which can identify impairment of talocrural mobility as early as possible. Considering that every therapy should be guided by pathophysiological phenomena that originate the problem, this information can be extremely useful in planning a clinical, physical and rehabilitating treatment. Indirectly, by increasing ROAM, CMP function will improve,^28-30 and as a result CVI consequences will be mitigated, avoiding morbid evolution of this process and improving individuals' quality of life.

Conclusion

CVI of the lower limbs is associated with reduced talocrural joint mobility, which can be identified by goniometry. This relationship is intensified and becomes more evident as clinical severity increases with presence of active or healed venous ulcer.

References

Manuscript received December 11, 2006, accepted May 17, 2007.

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Publication Dates

• Publication in this collection
  20 Sept 2007
• Date of issue
  June 2007

History

• Received
  11 Dec 2006
• Accepted
  17 May 2007