Does the Calcaneus Serve as Hypomochlion within the Lower Limb by a Myofascial Connection?—A Systematic Review

Round 1

Reviewer 1 Report

The paper is interesting. Some remarks were presented in the attached file.

Comments for author File: Comments.pdf

Author Response

1. Why definition of the hypomochlion was only discussed in 2.3 paragraph? It could be placed at

the very beginning of the paper and used to define the discussed problem.

- Thank you. We adjusted the structure of the results.

2. It is not clear if the main question discussed in the paper is: “Does the calcaneus serve as

hypomochlion within the lower limb” or “Are the Achilles tendon and the plantar fascia

connected to each other?” It could be interesting if Authors clearly state if both these aspects

should be taken into consideration together.

- We appreciate you pointing this out. With the lines 59 – 62 we added a clarifying

sentence to highlight the importance of both questions.

3. It is not clear why Authors use “dorsal lower limb” instead of simply “lower limb”.

- We agree with the anatomical accuracy and deleted the word “dorsal”

4. Some arguments used to indicate on the possible connection of the Achilles tendon and the

plantar fascia via the calcaneus are discussed without proper understanding of the biomechanics.

It is obvious that:

a. “The trabecular course of the calcaneus corresponded with the orientation of the collagen

bundles of the PF” (lines 94-95), because it’s the routine effect of bone tissue adaptation to

loadings acting on the trabecular structure (Wolff’s law)

- Thank you for this advice. This well known and widely accepted biomechanical

phenomenon is to be seen as a supportive argument for the connection of both

fascial structures. We added a sentence for clarification (183-184).

b. The dimensions (cross-sectional area) of the Achilles tendon and plantar fascia (lines 110-

112) are mainly based on strength criteria. If the forces carried by these anatomical

structures are similar, the dimensions should also be similar.

- Thank you for this advice. Since this was one of the results stated in the cadaveric

study, it ought to be mentioned. See 199

5. Is the best solution to present “4. Materials and Methods” after “2. Results” and “3. Discussion”?

- Concerning this, we are very open to the order of the chapters, the structure we

utilized was the one layed down in the template. If another order is of

preference and we misunderstood the template, we are happy to change the

structure.

-

6. The Achilles tendon should be written with capital letter.

- Thank you for this annotation. We corrected the text.

7. What was the role of Robert Schleip and Alison Agres as the author (lines 419-426)?

- Specificed at the according point

Author Response File: Author Response.pdf

Reviewer 2 Report

Thanks for the opportunity to review this  paper.

This is an interesting study. However, I have several comments that I hope the authors will find helpful.

My main concern is regarding the methodology. Authors should review SPIRIT checklist and flow diagram (https://www.equator-network.org/). Both of them should be included as part of the manuscript.

• Author should include the complete search strategy, not only the terms used (“achilles tendon”, “plantar fascia” “calcaneus”), Any language or publication year restriction?
• More information about databases. Why did you use just two? Why Livovo (Is not quite usual in other countries)
• Information about inclusion and exclusion criteria is limited. The complete information should be included in the flow diagram and/or text
• Considering the number of references (n=183) maybe authors should consider other database or “grey literature”
• “To identify studies for the systematic review of our research question two reviewers in-348 dependently screened all titles and abstracts.”. If the two reviewers didn’t agree how it was resolve?
• Conclusion: considering the limitations I’m not sure if there is a robust evidence (a few number of article, small sample size, different type (MRI, embalmed specimens…). Authors should consider the limitations to evaluate it.

Author Response

My main concern is regarding the methodology. Authors should review SPIRIT checklist and flow

diagram (https://www.equatornetwork. org/). Both of them should be included as part of the

manuscript.

- See 368-369

Author should include the complete search strategy, not only the terms used (“achilles tendon”,

“plantar fascia” “calcaneus”)

- See 373-374 and 383-385

Any language or publication year restriction?

- See 377-378

More information about databases. Why did you use just two? Why Livovo (Is not quite usual in

other countries).

- See 373-374, Livivo is very useful as it is comprehensive database and operator

which allows for a simultaneous search of numerous databases. This database

was set up by the German Federal Ministry of Education and Research (BMBF).

Information about inclusion and exclusion criteria is limited. The complete information should be

included in the flow diagram and/or text.

- See 378-382

Considering the number of references (n=183) maybe authors should consider other database or

“grey literature”

- We agree and recognize the fact that a comparably small number of references

met our inclusion criteria and discussed this in the limitations. We assume this to

be due to the fact that the topic is not well researched yet, is highly specific and

needs more attention, which we are trying to support with this paper.

- See 327-328, 435 - 439

“To identify studies for the systematic review of our research question two reviewers independently

screened all titles and abstracts.”. If the two reviewers didn’t agree how it was resolve?

- See 373-375

Conclusion: considering the limitations I’m not sure if there is a robust evidence (a few number of

article, small sample size, different type (MRI, embalmed specimens…). Authors should consider the

limitations to evaluate it.

- That is another important point and we integrated it, see 403-405