Plantar Heel Pain: The very common and uncommon

Transcription

1 Plantar Heel Pain: The very common and uncommon

2 Plantar Heel Pain Common clinical entity Common across age, activity, body type Treatment program varied, difficult to gage success of each So common, a set plan of care to treat is effective to follow patients Children: Calcaneal apophyitis (growth plate disturbance)

3 MULTIPLE TERMS Subcalcaneal pain Calcaneal bursitis Plantar fasciitis Fat pad atrophy Heel spur syndrome Calcaneodynia Nerve entrapment» 1 st branch (Baxter) Plantar Heel Pain

4 The Uncommon: DIFFERENTIAL DIAGNOSIS Flexor Hallucis Longus Tendinopathy Retrocalcaneal pain (achilles attachment) Soleus myofascial trigger point (Travell and Simon) Calcaneal stress fracture (very rare) Tarsal Tunnel Syndrome Radiculopathy of S1 Inflammatory Conditions Reiter s syndrome Neuropathic Conditions

5 ANATOMIC CONSIDERATIONS Calcaneus Muscle Attachment Fascia Attachment Bursa Nerve course

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8 Movement consideration Common condition in runners Common condition in non-athletic population Risk factor: (Riddle, JBJS, 2003) Restricted ankle DF Obesity Weight bearing work day activity Arch type

9 Clinical Practice Guidelines Ankle Sprain JOSPT ( Sept. 2013) Risk Factors Diagnosis Classification Differential Diagnosis Examination Intervention Acute/Protected Motion Phase Early WB with support Manual Therapy Physical Agents Progressive Loading/Sensory Motor Training Phase Manual Therapy Therapeutic Exercise Sports-Related Activity Training Therapeutic Exercise

10 Clinical Practice Guidelines Heel Pain-Plantar Fasciitis Orthopaedic Section published JOSPT McPoil, 2008 Martin, 2014 What has changed How does this help you How does this not help you

11 Clinical Practice Guidelines Heel Pain-Plantar Fasciitis Revision (2014) Risk Factors Foot type more pronation Runners Diagnosis Classification High BMI non athletic pt. Differential Diagnosis Non musculoskeletal conditions Fat pad atrophy Examination Outcome measures Foot Posture Index Joint accessory motion Intervention Manual Therapy Stretching Taping Foot orthoses Night splint Modalities Foot wear selection Weight loss education Therapeutic Exercise Dry Needling (came in late)

12 Demographics Onset MOI AGG/ALLEV 24 hour symptoms Medication Helpful or not Acute or Chronic? Inflammatory vs Degenerative? History

13 SYMPTOMS Pain on first step in the morning Pain on standing after prolonged sitting Gets better once moving Gets worse again at end of day Better usually in shoes than barefoot Rarely can they state a particular injury (insidious onset) Swelling: usually never Can have traumatic rupture of plantar fascia

14 Body weight Plantar aponeurosis

15 Abnormal Pronation in Terminal Stance Lose Windlass Mechanism Assists in supination of foot Length tension of intrinsics Stress on to forefoot Overload into posterior tibial muscle tendon complex. Neumann

16 Heel Pain-Plantar Fasciitis Clinical Practice Guideline Orthopaedic Section published JOSPT McPoil, 2008 Martin, 2014 What has changed How does this help you How does this not help you

17 What are findings common to plantar heel pain? 23 patients reviewed with plantar heel pain What was found? Pain: 22/23 AM pain on rising 20/23 pain on rising after prolonged sitting Posture: report on 14 12/14presented increase weight on heels Trunk posterior

18 What are findings common to plantar heel pain? Observational gait analysis 7/23 demonstrated heel avoidance 13/23 demonstrated abnormal pronation 3/23 demonstrated normal pronation Range of motion 23/23 restricted ankle DF (10 degrees as normal) 10/23 restricted subtalar eversion 6/23 restricted first MTP DF

19 What are findings common to plantar Weakness heel pain? posterior tibial 17/23 MMT peroneals 14/23 MMT anterior tibial 2/23 MMT calf 10/23 25 SL HR Pain in walking used Visual Analog Scale (0-10) rated during walking in clinic before and after Neural Mobility Testing

20 What are findings common to plantar heel pain? Neural Mobility Testing Straight Leg Raise 16 decreased pain, 2 no change (5 no report) VAS: pre 3.7 post 1.6

21 Assessment of Nerve Mobility History David Butler Robert Elvey Meyer (2002) case study Alshami, Coppieters. Ellis Screen LE before exam! Intent is anticipating feeling for change Patient & therapist engaged Sequence SLR Hip ADD and IR Tibial N bias Ankle DF and pronation Butler suggests when distal symptoms reverse test.

22 LOWER LIMB TENSION TEST PROXIMAL TO DISTAL DISTAL TO PROXIMAL

23 Tibial nerve course Soleus canal Tarsal Tunnel Travell and Simon

24 Neural Mobility in Heel Pain Tibial nerve at soleus canal at tarsal tunnel first branch lateral plantar nerve (Abd. Dig. Min.) Daniels et al Pronation leads to increase stress on tibial nerve Baxter et al surgical neurolysis presented Meyer 2002 JOSPT Case Presentation

25 Excessive femoral rotation? Excessive Tibial rotation? Altered Foot Mechanics Excessive Pronation? Rearfoot? Midfoot/forefoot? Muscle tightness? Joint restriction? Muscle weakness? Joint hypermobility?

26 Variability of normal

27 Treatment for Plantar Heel Pain Multiple structures Difficult to determine Complete assessment Neural mobility is an issue in these patients until proven otherwise Care taken in neural mobility testing Restore length/gliding Joint mobilization calf flexibility neural mobility Restore stability muscular control external support tape, foot orthoses Control fat pad best shock absorption

28 Plantar Fascia Stretch DiGiovanni, JBJS, 2003 DiGiovanni, JBJS, 2006 Plantar foot structures When need to advance stretch consider in weight bearing.

29 Calf Stretching Fix one end of the muscle Lengthen the muscle with movement Gastrocnemius Soleus Deep posterior compartment.

30 Multiple techniques Directed at foot, ankle, knee, hip Standard HEP Manual Therapy Cleland

31 Arch tape: One way, in your handout Instruction Demonstration to patient Suggested of use 4 weeks Better: YES/NO Stop tape, what happens? Continue reduced symptoms Symptoms return?

32 Foot Orthoses What did tape do? Consistent HEP Best available footwear Cost Foot shape Device? Over The Counter Custom FURTHER DISCUSSION COMING