74 - Heel Pain Flashcards
1
Q
Plantar fascitis
A
- Plantar stress, tendinitis and inflammation of the plantar fascia with or without a spur or inferior calcaneal exostosis
- “Heel Spur Syndrome” is a common diagnosis from family medicine, but we tend to not worry about the spur itself – there are plenty of people who have a spur without heel pain or heel pain without a spur
- 11% of US population and 73% of patients with heel pain have a spur
- Etiology and treatment of plantar fascitis controversial
2
Q
Etiology
A
- Repetitive traction with inflammation
- There is a subset of people who do not believe there is inflammation present and therefore refer to it as plantar fasciosis
- Pronation
- Increased body weight or activity – can see it during the 3rd trimester of pregnancy or in New Year’s Resolutioners (increased activity)
- Systemic or rheumatological disorders – these can be a precursor to conditions of the plantar fascia
3
Q
Differential diagnosis of pain in the subcalcaneal area
A
- Bursitis (can be so large you see a radiopaque bursa under calcaneus on x-ray)
- Contusion/Stress Fracture (especially in runners who have increased mileage)
- Tendinitis (especially Achilles tendon)
- Nerve entrapment (medial calcaneal branch or nerve to adductor digiti minimi or Baxters nerve
- Neuroma
- Herniation of fascia or rupture (can actually be curative – they ruptured it on their own instead of having a surgical release)
- Systemic Disease (diabetics can have pain at insertions of tendons or fascia)
- Infection (VERY rare)
4
Q
Diagnosis of plantar fascitis
A
- Radiating, deep aching heel pain
- Post-static Dyskinesia (pain when they first get up in the morning, starts to get better with activity, hurts again after sitting down – Remember, can have atypical presentation)
- Pain of palpation, Hubscher Maneuver (dorsiflex hallux to tighten plantar fascia – causes pain)
- Radiographs-Saddle Sign (inferior bone spur looks like the saddle of a horse)
- Laboratory Studies (only do this if worried about infection)
- Bone Scans (if patient isn’t responding to conservative treatment, atypical presentation, etc. – could look for stress fracture)
- MRI (rarely get an MRI, but looks for bone cyst, bone tumor, stress fracture if bone scan was inconclusive)
- If the pain radiates, I lean toward a neurological diagnosis
5
Q
Image of bone spur
A
- We tend to not worry about this spur
- Does not indicate pain
- Just a sign that the fascia is most likely tight and thickened
- Can cause remodeling of plantar fascia
- Some surgical approaches do not address the spur and they do fine
6
Q
Treatment
A
- Taping to support the arch
- NSAIDs (some won’t if they don’t believe it is inflammation, but he still does)
- Ice (can decrease pain and inflammation)
- Physical therapy (directed at stretching the plantar fascia, if equinus is a problem as well, they can stretch Achilles tendon as well)
- Orthotics (can be effective in some patients)
- Injections/Medrol Dose Pack (inject anti-inflammatory corticosteroid or oral corticosteroid – side effects of insomnia/jittery rush with oral)
- Night splints
- Immobilization (in severe cases – non-WB for a period of time)
- Platelet-Rich Plasma injection along with some form of needling as well
- Surgery
- NOTE: this order changes based on the physician you are working with
7
Q
Night splints for plantar fascia pain
A
o Meant to increase dorsiflexion or stretch Achilles tendon
o Adjustable and very uncomfortable
o I have not met a patient who can tolerate these all night)
8
Q
Surgery for plantar fasiciitis
A
o if conservative treatment is not effective
o Usually conservative measure are very successful, so you will rarely need to take the patient to surgery
o 93%-95% of patients are successful with conservative treatment
9
Q
STUDY: Monto, R.R. (2014). Platelet-rich plasma efficacy versus corticosteroid injection treatment for chronic severe plantar fascitis. FAI
A
- Level 1 – prospective randomized comparative series
- 40 patients with unilateral PF who did not respond to 4 months of conservative treatments
- AOFAS initial, 3, 6, 12 and 24 months
- DepoMedrol – 52,81,74,58,56
- PRP – 37,95,94,94,92
- There WAS an increase in the score, then it started to drop – not sure if it was funded by industry or not
- RESULTS: The cortisone group had a pretreatment average AOFAS score of 52, which initially improved to 81 at 3 months posttreatment but decreased to 74 at 6 months, then dropped to near baseline levels of 58 at 12 months, and continued to decline to a final score of 56 at 24 months. In contrast, the PRP group started with an average pretreatment AOFAS score of 37, which increased to 95 at 3 months, remained elevated at 94 at 6 and 12 months, and had a final score of 92 at 24 months.
- CONCLUSIONS: PRP (platelet rich plasma) was more effective and durable than cortisone injection for the treatment of chronic recalcitrant cases of plantar fasciitis.
10
Q
Plantar fasciotomy
A
- Plantar Fascial Release (with or without spur resection)
o Instep Fasciotomy
o Open
o Endoscopic Plantar Fasciotomy(EPF) - Instep and endoscopic have less complications and shorter recovery time
11
Q
Instep fasciotomy
A
- Incision in medial arch ANTERIOR to calcaneus – this means you are not in the same area to resect the spur
- Medial portion of fascia released
- There will be adipose tissue over top of the fascia, which will need to be moved out of the way
- Very quick procedure – takes less than 15 minutes
12
Q
Advantages of instep fasciotomy
A
o Recovery time is shorter
o Visibility – great visibility of the plantar fascia
13
Q
Distadvantage of instep fasciotomy
A
o Resection of exostosis - can’t resect it
14
Q
Open plantar fasciotomy
A
- Medial incision to visualize the plantar fascia
- Fascia isolated superior and inferior
- Post-op crutches for 2-3 weeks due to possibility of hematoma as well as high pain that the patient will be in
- Near to medial branch of calcaneal nerve – possibility of neurovascular damage
- This procedure is NOT done very much, so he didn’t even include a picture
15
Q
Advantages of open plantar fasciotomy
A
o Visibility
o Resection of exostosis
