Plantar Heel Pain By: Kevin Kleiner, M.B.S. New York College of Podiatric Medicine
Plantar Heel Pain: - Many Etiologies but few solutions Plantar heel pain more specifically: Heel pain felt in ones rear-foot secondary to biomechanical insufficiency
The Most Important Point: - Heel Pain is not a diagnosis (so don t add it to your patient charts / Meditrek) - Heel Pain is a SECONDARY manifestation of an underlying musculoskeletal, orthopedic, biomechanical or metabolic cause. - The Main Focus of my assignment: Go through the underlying causes of heel pain - and their differential diagnosis and treatment modalities
Incidence and Prevalence Plantar Heel Pain: Affects almost all people at some point in their lives - Over 2 million people are estimated to be treated each year - Less common in people < 30 y/o - Peak incidence +/- 40-60 y/o - Estimated that 1 in 10 will experience it within their lifetime Study : Sample of 4,060 > 18yo - Estimated that 1 in 5 will experience it within their lifetime
Background Anatomical Information Plantar Heel Pain 1) Most commonly occurs within the region of contact between the medial and lateral calcaneal tubercles and GRF. 2) There are many other bony regions traversed by extrinsic tendons, ligaments, muscle origins that can have pathology leading to plantar heel pain 3) Nerve branch points from leg into plantar foot
Plantar Heel Pain Posterior Heel Pain! Not be be confused with Posterior heel pain:! Achilles insertion! Posterior compartment tendons passing into the foot! Ligamentous attachments! Ossification centers
Clinical Presentation & Evaluation
- What is the most common Primary* cause of plantar heel pain: Subjective Evaluation: What does the patient describe? N.L.D.O.C.A.T N & L: Sharp, stabbing, tightness @ plantar medial heel deep to medial calcaneal tuberosity D. Hours " Days " Weeks " Months O. Pain in heel after waking upon ambulation, after prolonged sitting, C. Typical for pain to improve after time throughout day with peak later on A. Basically: Everything is an aggravating factor T. Objective Evaluation: What do we observe? - Thorough H&P is KEY - Potential Gait abnormalities such as: Equinus to avoid painful area - Elicit sharp pain on palpation @ plantar medial aspect of heel on medial calcaneal tuberosity - Pain during passive ankle dorsiflexion - Pain during passive 1 st MPJ dorsiflexion
Plantar Fasciitis - Most common Primary cause of plantar heel pain Subjective Evaluation: What does the patient describe? N.L.D.O.C.A.T N & L: Sharp, stabbing, tightness @ plantar medial heel deep to medial calcaneal tuberosity D. Hours " Days " Weeks " Months O. Pain in heel after waking upon ambulation, after prolonged sitting, C. Typical for pain to improve after time throughout day with peak later on A. Basically: Everything is an aggravating factor T. Objective Evaluation: What do we observe? - Thorough H&P is KEY - Gait abnormality: Equinus to avoid painful area - Elicit sharp pain on palpation @ plantar medial heel deep to medial calcaneal tuberosity: **Pain is non-radiating - Pain during passive ankle dorsiflexion - Pain during passive 1 st MPJ dorsiflexion
Plantar Fasciitis - Most common Primary cause of plantar heel pain - Inflammation in area of plantar fascial bands origin @ medial calcaneal tubercle - Over activity (runners, commuters etc..), obesity " Excessive stretching of fascial band without adequate time to lessen inflammation - Excessive stretch of fascia " decrease in arch support / rear foot support " Pain
Plantar Fasciitis Origin: Anterior calcaneal process Insertion: Spreads and separates into 5 fascicles to each of 5 toes ending as part of MPJ capsules. - Pain during passive ankle dorsiflexion - Pain during passive 1 st MPJ dorsiflexion
Calcaneovalgus Flexible Congenital Flatfoot: Clinically: Presents as - Excessive dorsiflexion at ankle and *Eversion* of rear foot - Foot position in classic Up and Out position - Forefoot is abducted and everted - Deep creases of skin lines at ankle anterolaterally
Aquired Pes Planovalgus (Flexible Congenital Flatfoot) - Results from weakening of ligamentous or tendinous to bone relationships - Excess weight - - Collapse and lowering of medial arch Clinically: Presents as - Flexible on R.O.M - Excessive eversion or valgus of rearfoot - Decrease in medial arch height on weight bearing - Abnormally prominence of medial malleolus - Forfoot abducted on rearfoot with heel eversion - (+) Too many toes sign
Calcaneal Fat Pad Atrophy - Calcaneal fat pad is an anatomical structure with fat-filled compartments divided by septae - Shock Absorption - Resistance to shear forces between foot during gait against ground reactive forces - Approximate start of septal breakdown 40y/o " Atrophy of fat pad
Differential Diagnosis
Differential Diagnosis 1) Posterior ankle impingement (PAI) Caused by repetitive acute foot plantarflexion - Ballet Dancers " Talus and soft tissue compression between calcaneus and tibia " Lesions to bone and surrounding soft tissue How would this cause plantar heel pain?
Dr. Novella: Importance of adequate heel height related to pain from a posterior ankle impingement - Higher medial load force applied to knee - Higher frontal plane forces applied to the ankle (eversion) via higher heel height leads to increased stress
Differential Diagnosis 2) Nerve Entrapment: Tarsal Tunnel Syndrome: 2) - P.T nerve entrapment - Parasthesia: burning / itching / tingling - Pain is *radiating and not contained in heel alone - Positive (+) Tinnels Sign @ Post. Tib Nerve (Tapping of nerve elicits sensation of electric shock
Differential Diagnosis - L5-S1 radiculopathy - Peripheral neuropathies: - Diabetic, Hypothyroidism - Infection - Cancer - Tendonitis - Tendon rupture
Tests! Squeeze test:! Compression of tuberosity of the heel! If: moderate to severe pain = Stress Fracture! Nerve Conduction Studies: (To rule out nerve entrapment)!! Imaging studies: (next slide)
Tests! X-ray: Later View can be done but does not contribute much to its diagnosis if plantar fasciitis is the cause.! Ultrasound: To rule out a fragmented bone spur at calcaneus or soft tissue abnormality! T2 MRI: Is very effected although not commonly done! Can measure thickness change of plantar fascia
Treatment: If Plantar Fasciitis: - Rest, Ice, Compress, elevate. Main goal is to stay off the foot long enough to allow dec inf. - Stretching exercises: - Towel under arch method - Frozen water bottle under arch method - Heel raise/knee flex against wall method - Cortisone injection at medial tubercle - Not recommended because leads to soft tissue breakdown
Treatment: Use of orthotics to correct orthopedic biomechanical problem is The most common treatment modality Plantar Fasciitis / Fat pad atrophy: - Hard heel cup [MF Heel Protector] [Cranston] - Viscoheel SofSpot: Silicone heel cusion [Bauer-Feind Works via low durometer silicone pad to disperse weight at plantar tubercles CFO: Custom Foot Orthoses: Most effective: 78% injuries resulting from running returned to running postinjury after recovery.
Treatment: - Endoscopic plantar fasciotomy in the treatment of chronic heel pain Patients underwent upon T2 MRI diagnostic confirmation for fascia release.
Treatment: Night Splint: Kept foot in dorsiflexed locked position over night concurrent with stretching exercises & NSAID Medial Wedge/Rearfoot varus post on UCBL shown effective in flexible flatfoot and for Ankle Impingement of P.T nerve
Bibliography 1. ELLEN SOBEL, DPM, PhD* STEVEN J. LEVITZ, DPM MARK A. CASELLI, DPM Orthoses in the Treatment of Rearfoot Problems J Am Podiatr Med Assoc. 1999 May; 89(5): 220 233. 2. JOHN CONNERS D.P.M, ELISSA WERNICK D.P.M, LAURENCE J. LOWY D.P.M, RUSSEL G. VOLPE D.P.M: GUIDELINES FOR EVALUATION MANAGEMENT OF FIVE COMMON PODOPEDIATRIC CONDITIONS J.American Podiatric Med Assoc. 88(5): 206-222, 1998 3. JAMES D. GOFF, DO, and ROBERT CRAWFORD, MD, Diagnosis and Treatment of Plantar Fasciitis American Family Physicians. Volume 84: (6), 2011 4. E. Pepper Toomey, M.D, Plantar Heel Pain Foot Ankle Clin N Am 14 (2009) 229 245 5. Catherine L Hill*1, Tiffany K Gill, Hylton B Menz and Anne W Taylor, Prevalence and correlates of foot pain in a population-based study: Journal of Foot and Ankle Research 2008, 1:2 6. Bonanno et al.: The effect of different depths of medial heel skive on plantar pressures. Journal of Foot and Ankle Research 2012 5:20. 7. Edwin P. Urovitz, MD; Alexandra Birk-Urovitz; Elizabeth Birk-Urovitz; Endoscopic plantar fasciotomy in the treatment of chronic heel pain Can J Surg, Vol. 51, No. 4, August 2008 8. Nathalie J. Bureau, MD, FRCPC, Étienne Cardinal, MD, Posterior Ankle Impingement Syndrome: MR Imaging Findings in Seven Patients l'université de Montréal, 1058, rue Saint-Denis, Montréal, Québec Canada, H2X 3J4 (N.J.B., E.C., B.A.),