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Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."
Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011
Dr. Shankar P.R.
"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."
Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011 Anuradha
Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.
Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020
Original article / research
Full Version
Detecting Presence of Tarsal Tunnel Syndrome in Type II Diabetic Patients using Clinical, Radiological and Electrodiagnostic Studies: A Cross-sectional Study
Correspondence Address :
Dr. Shrikant Manwatkar,
Department of Surgery, Command Hospital Air Force, Cambridge Road, Bengaluru-560007, Karnataka, India.
E-mail: shrikantxy@gmail.com
Introduction: Diabetic foot is one of the most devastating complications of diabetes and is the leading cause of lower limb amputations. Patients with a long-standing history of diabetes mellitus often experience symptoms of pain, burning sensation, numbness, and paraesthesia in the heel and feet. These symptoms may be due to compression of the medial plantar nerve, a branch of the tibial nerve, within the tarsal tunnel.
Aim: To evaluate the incidence of Tarsal Tunnel Syndrome (TTS) in patients suffering from Type 2 Diabetes Mellitus (T2DM).
Materials and Methods: This study was a cross-sectional analysis conducted at the Army Hospital (Research and Referral) in New Delhi, India, from October 2019 to April 2021. A total of 30 consecutive diabetic patients presenting with pain, burning, numbness, and paraesthesia in the heel or feet, with or without ulcers, were included. All patients were clinically evaluated using three-point sensory testing, Tinel’s sign at the tarsal tunnel, and assessment for the presence of ulcers on the foot. All patients underwent Nerve Conduction Velocity (NCV) studies. Imaging studies in the form of Magnetic Resonance Imaging (MRI) were performed for a complete work-up of these patients and further diagnosis of TTS. The incidence of TTS was evaluated using clinical, radiological and electrodiagnostic studies.
Results: Of the 30 patients enrolled, 20 were males (66.7%) and 10 were females (33.3%). The incidence of TTS among diabetic patients was found to be 14 (46.7%) based on electrodiagnostic criteria, 22 (73.3%) based on clinical evaluation, and 25 (83.3%) based on radiological findings. The mean HbA1c level was 8.5±1.04%. The most common imaging finding was oedema, observed in 83.3% of patients. Inflammation and ganglion cysts were seen in 13.3% and 10% of patients, respectively.
Conclusion: TTS is difficult to diagnose. MRI is a useful imaging modality to support the diagnosis. Electrodiagnostic studies can help confirm the diagnosis.
Diabetic neuropathy, Electrodiagnostic study, Entrapment neuropathy, Magnetic resonance imaging
Diabetes is responsible for significant morbidity worldwide. The prevalence of diabetes was 171 million in 2000 and is projected to reach 366 million by 2030 globally. In India, more than 62 million individuals are affected by diabetes (1). Diabetic foot is one of the most devastating complications of diabetes and is the leading cause of lower limb amputations. It poses a risk of disability, with frequent hospital stays often resulting in limb amputation. The prevalence of diabetic ulcers among diabetics worldwide is 4-10% (1). The severity of diabetic foot can be assessed using the Wagner classification. In grade 0, there is no open ulcer. In grade 1, there is destruction of the thickness of the skin. Grade 2 ulcers penetrate through the skin, fat, and ligaments but do not affect bone. In grade 3, there is involvement of deeper tissues with abscesses, osteomyelitis, or tendonitis. Grade 4 consists of limited necrosis in the toes or the forefoot, while grade 5 indicates necrosis of the whole foot (2).
Diabetic neuropathy is a common accompanying factor in almost 90% of diabetic ulcers (2). About 80% of these ulcers are neuropathic in origin, while the remaining 20% are neuroischaemic. According to the American Diabetes Association (ADA), a foot that has lost its protective sensation is considered to be at “risk” for ulceration (3). Patients with a long-standing history of diabetes mellitus often experience symptoms such as pain, burning sensations, numbness, and paraesthesia in the heel and feet. These symptoms can result from compression of the medial plantar nerve, a branch of the tibial nerve, within the tarsal tunnel.
TTS is an entrapment neuropathy associated with the compression of structures within the tarsal tunnel (4). It is similar to carpal tunnel syndrome of the wrist, although much less common (5). TTS is associated with 80% of diabetic patients at risk for foot complications and often remains underdiagnosed, leading to a range of symptoms affecting the plantar margins of the foot (6). Clinically, TTS can be identified by Tinel’s percussion test over the nerve, and hypoesthesia in the foot is assessed using the Semmes-Weinstein 10 g filament (7).
TTS is suspected based on the patient’s symptoms and diagnosed through electrodiagnostic tests. The following tests are required to assess TTS electrodiagnostically:
1. Distal Motor Latency (DML)
2. Sensory Conduction Velocity (SCV)
3. Amplitude of Sensory Nerve Action Potential (SNAP)
Radiological investigations are also important for identifying the causes of TTS, such as ganglion cysts and oedema of the surrounding structures. MRI is the most effective tool for assessing the contents of the tarsal tunnel, the flexor retinaculum, and the branches of the tibial nerve (8).
After reviewing the literature on various studies, authors found that TTS presents in a significant number of diabetic patients who exhibit subjective neuropathic symptoms in their feet, as many of the symptoms of TTS mimic those of diabetic neuropathy (9). Therefore, TTS should be considered during the diagnostic work-up and management of diabetic patients. Consequently, this study was conducted to determine the incidence of TTS in patients suffering from T2DM. Hence, the aim of the study was to evaluate the effectiveness of different diagnostic modalities, including electrodiagnostic and radiological studies.
This study was a cross-sectional study conducted at the Army Hospital (Research and Referral) in New Delhi, India during the period from October 2019 to April 2021. Ethical clearance was obtained from the hospital’s ethical clearance committee (IEC No: 74/2019). Patients of any ethnicity or age from across the country who were referred to or brought to this hospital were enrolled. The patients came from both rural and urban backgrounds. Those who agreed to participate in the study provided signed written informed consent and satisfied the following inclusion criteria.
Inclusion criteria: Patients with a confirmed diagnosis of diabetes, with or without ulcers (early stages of Wagner classification (2) in the foot), at the Department of General Surgery of a tertiary care hospital were included in the study.
Exclusion criteria: Patients with diabetic foot selected for amputation and further flap coverage were excluded from the study, as these individuals would not be able to undergo testing for TTS after amputation. Patients with vascular insufficiency (Ankle-Brachial Pressure Index [ABPI] <0.7) were also excluded, as ischaemic pain due to vascular insufficiency would hinder the diagnosis of TTS. Patients in severe sepsis or those who were unstable were excluded from the study, as they would not be able to undergo testing for TTS. Additionally, patients with later stages of Wagner ulcers, as those would typically require amputation were excluded from the study.
Study Procedure
Thirty consecutive diabetic patients presenting with pain, burning, numbness, and paraesthesia of the heel or feet, with or without ulcers, were evaluated. All patients were tested for fasting and postprandial blood sugar levels and HbA1c. Clinically, all patients were evaluated through a three-point sensory testing using Semmes-Weinstein 10 g filaments (measured on a scale of 0 to 10 at a minimum of four sites: heel, toe, lateral malleolus, and medial malleolus), Tinel’s sign at the tarsal tunnel, and the presence of ulcers on the foot. All patients underwent Nerve Conduction Velocity (NCV) studies performed by a neurologist at this hospital, which included assessments of distal motor and sensory latency and Sensory Nerve Action Potential (SNAP). Imaging studies in the form of MRI were conducted for a complete work-up of these patients and further diagnosis of TTS.
Statistical Analysis
All demographic data, clinical examination results, nerve conduction study results, and MRI findings were recorded in an MS Excel spreadsheet. The data were coded and analysed using Statistical Package for Social Sciences (SPSS) version 23.0 (IBM Corp). Descriptive statistics were generated using means/standard deviations and medians/Interquartile Ranges (IQRs) for continuous variables, and frequencies and percentages for categorical variables. Group comparisons were performed using the Chi-square test. Sensitivity of the test was calculated by dividing the number of true positives by the sum of true positives and false negatives. Specificity of the test was calculated by dividing the number of true negatives by the sum of true negatives and false positives. Statistical significance was set at a p-value of 0.05.
The mean age of presentation was 61.4±11.2 years, and the median age was 59 years. Of the 30 patients enrolled, 20 were males (66.7%) and 10 were females (33.3%) (Table/Fig 1).
The mean fasting blood sugar and postprandial levels were 163.7±78 mg/dL and 228.5±84.3 mg/dL, respectively. The mean HbA1c level was 8.5±1.04% (Table/Fig 2). The incidence of TTS in diabetic patients was found to be 14 (46.7%) electrodiagnostically, 22 (73.3%) clinically, and 25 (83.3%) radiologically.
The most common finding in the imaging conducted was oedema, which was observed in 25 (83.3%) patients. Inflammation and ganglion cysts were seen in 4 (13.3%) and 3 (10%) patients, respectively (Table/Fig 3).
Tinel’s sign was positive in 22 (73.3%) of patients. Additionally, 10 (33.3%) of patients exhibited a loss of sensation when measured on a scale of 10 at a minimum of four sites (heel, toe, lateral malleolus, and medial malleolus). Non healing diabetic ulcers were present in 17 (56.7%) of patients (Table/Fig 4).
On electrodiagnostic studies, the motor amplitude was not recordable in 10 (33.3%) of patients. The H reflex was not recordable in 21 (70%) of patients, and the sensory amplitude was not recordable in 26 (86.7%) of patients (Table/Fig 5).
The positivity of Tinel’s sign was significantly associated with electrodiagnostic confirmation of TTS (p-value=0.0001). The monofilament test was also significantly associated with electrodiagnostic confirmation of TTS (p-value=0.039) (Table/Fig 6).
Clinical findings were confirmed by electrodiagnostic findings in 17 (56.7%) of patients. Radiological confirmation of TTS was corroborated by electrodiagnostic studies in 15 (50%) of patients. The clinical findings of TTS were confirmed by radiological findings in 80% of patients (Table/Fig 7).
The sensitivity of the association between clinical findings and electrodiagnostic studies was 78.57%, with a specificity of 62.5%. The sensitivity of the association between radiological findings and electrodiagnostic studies was 92.86%, with a specificity of 87.5%. The sensitivity of the association between clinical findings and radiological studies was 87.5%, with a specificity of 50% (Table/Fig 8).
In this study, the mean age of presentation was 61.4±11.2 years, with a male predominance (66.7%). A similar study by Rinkel WD et al., which examined 113 patients in the Netherlands, reported a comparable mean age of 62.7 years (10).
Examination also included Tinel’s sign, which involves light tapping over the nerve to elicit a sensation of tingling or “pins and needles” along the distribution of the nerve. It is considered positive when the tingling or prickling sensation is felt. This sign was found to be positive in 73.3% of patients, with a significant p-value of 0.0001. Cimino WR found this in all 97 patients in their review of the literature (11). Linscheid RL et al., found that Tinel’s sign was positive in 24 out of 34 patients in their study conducted in Atlanta (12).
MRI findings suggestive of oedema were the main reason for compression of the common peroneal nerve and tibial nerve in the tarsal tunnel. Oedema was the predominant finding present in 25 patients (83.3%). Jung HJ et al., conducted a study on 33 patients in Incheon, Korea, and suggested that MRI is excellent for demonstrating musculotendinous and neurovascular structures (8). MRI can clearly reveal the anatomy of the tarsal tunnel and its contents, along with the presence or extent of space-occupying lesions leading to TTS (13). Kerr R and Frey C found that oedema was the main factor associated with inflammation of the tibialis posterior tendon within the tunnel (14).
Sensory nerve conduction studies were more sensitive and yielded more convincing diagnostic findings. Approximately 26 patients (86.7%) had no recordable potentials, while four patients (13.3%) had normal findings. Patel AT et al., found that SNAP were absent in 92.8% of patients with TTS, while mixed nerve conduction studies were abnormal in 85.7% of patients (15). Sodani A et al., conducted a study on 40 patients in India and found that motor nerve conduction studies were significantly abnormal in patients with TTS (16). These findings are quite comparable to those of present study.
This was a single-centre study. All three modalities for diagnosing TTS-clinical, radiological, and electrodiagnostic studies-were used in this study. Longer follow-up durations and further studies are needed to ascertain the impact of these factors on long-term complications in type II diabetic patients.
Limitation(s)
The study had a small sample size. Patients with diabetic foot at risk who had a low Wagner’s grade were included in the study, while those with a higher Wagner’s grade were excluded.
The diagnosis of TTS can be challenging. It is primarily based on clinical examinations such as the monofilament test, Tinel’s sign, and the assessment of diabetic ulcers. To further support the diagnosis, imaging modalities like MRI can be useful for evaluating the depth of the tunnel and the status of the underlying structures, including oedema, inflammation, and compression due to synovial fluid effusion or ganglia. Additionally, electrodiagnostic studies can help confirm the diagnosis.
Authors acknowledge the support and help provided by Department of Radiology and Department of Neurology, Army Hospital (Research & Referral), New Delhi in carrying out this study.
Author’s contribution: Study conception and design was done by VK and MAP. Data collection was done by VK, SD, SC, RM and AK. Analysis and interpretation of results was done by PD and VK. Draft manuscript preparation was done by VK and SM. All authors reviewed the results and approved the final version of the manuscript.
DOI: 10.7860/JCDR/2024/70950.20282
Date of Submission: Mar 30, 2024
Date of Peer Review: May 17, 2024
Date of Acceptance: Sep 04, 2024
Date of Publishing: Nov 01, 2024
Author declaration:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA
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