Conservative Heel Pain Treatment
Brian K. Bailey, DPM, MS Podiatric Physician & Surgeon Ashland, KY (606) 324-FOOT (3668)
http://www.pandoracats.com/BMSPC/BMS PCmain.html Plantar Fasciitis Plantar Fasciitis Inflammation and pain along the plantar fascia - the tissue band that supports the arch on the bottom of the foot
Usually on the bottom of the heel at the point where the plantar Plantar fascia attaches to the heel bone Becomes chronic in 5-10% of all Fasciitis patients Is not necessarily associated with a heel spur
Over 90% resolve with conservative treatment Plantar Fasciitis Symptoms
Pain on standing, especially after periods of inactivity or sleep
Pain subsides, returns with activity
Pain related to footwear – can be worse in flat shoes with no support
Radiating pain to the arch and/or toes
In later stages, pain may persist/progress throughout the day
Pain varies in character: dull aching, “bruised” feeling. Burning or tingling, numbness, or sharp pain, may indicate local nerve irritation Other Potential Causes of Heel Pain
Calcaneal Stress apophysitis Arthritis Gout fracture (children)
Achilles Pinched tendon Bone cyst nerve/Nerve Neuropathy problems entrapment
Low back or disk problems What is the diagnosis? Also called “adult- acquired flat foot” and "progressive flatfoot," PTTD occurs when inflammation or damage to the posterior Posterior tibial tendon reduces its ability to support the arch. Tibial This often results in flattening of the foot, meaning the entire foot Tendon touches the floor when you’re standing. Although Dysfunction PTTD usually occurs in only one foot, some people may develop the condition in both feet. It typically will continue to get worse, particularly if it is not treated early. Posterior Tibial Tendon Dysfunction
Symptoms
The symptoms of PTTD may include pain, swelling, a flattening of the arch, and an inward rolling of the ankle.
When PTTD initially develops, there is pain on the inside of the foot and ankle (along the course of the tendon). In addition, the area may be red, warm, and swollen.
As the arch begins to flatten, there may still be pain on the inside of the foot and ankle. But at this point, the foot and toes begin to turn outward, and the ankle rolls inward.
As PTTD becomes more advanced, the arch flattens even more and the pain often shifts to the outside of the foot, below the ankle. The tendon has deteriorated considerably, and arthritis often develops in the foot. In more severe cases, arthritis may also develop in the ankle. Posterior Tibial Tendon Dysfunction
Diagnostic feature is the patient’s inability or difficulty in performing a unilateral heel raise.
Weakness inverting their foot Posterior Tibial Tendon Dysfunction
Treatment Mild PTTD is treated similarly to plantar fasciitis Moderate to severe PTTD requires bracing Start with a Swedo brace and schedule for casting for an AFO Baxter’s nerve entrapment The first branch of the lateral plantar nerve becomes entrapped in the medial heel
With entrapment, the pain is more localized, it is pressure sensitive, Baxter’s and gets worse with activity rather nerve than better. Usually responds well to ultrasound entrapment guided corticosteroid injections
Injections only treat the symptoms, so it is essential to treat the causative underlying biomechanical abnormalities Tarsal Tunnel Syndrome Tarsal Tunnel Syndrome
Entrapment of posterior tibial nerve The most common cause is repetitive pronation/supination Pronation causes narrowing of the tarsal tunnel Positive Tinel’s and Valleix's sign Tarsal Tunnel Syndrome
In a study published in Foot and Ankle International, Trepman et al. proved that eversion and inversion of the foot and ankle increased pressure in the tarsal tunnel, contributing to symptoms associated with entrapment of the posterior tibial nerve
By obtaining the MR I of 13 ankles in nine healthy subjects in three positions (neutral, eversion, and inversion), the authors observed that the mean tarsal tunnel volume was significantly greater when the foot and ankle were in the neutral position rather than in the full eversion or inversion.
The findings of this study imply that maintaining the foot and ankle in a neutral position can help in the treatment and management of tarsal tunnel syndrome by reducing pressure on the posterior tibial nerve and maximizing compartment volume of the tarsal tunnel. Tarsal Tunnel Syndrome
What are some of Treatment of TTS the risk factors and plantar fasciitis these two causes are quite similar of heel pain share? Plantar Fasciitis Risk Factors
Biomechanical abnormalities Overly tight calf muscle Poor shoe choices Weight gain Barefoot walking Work surface Trauma Plantar Fasciitis Evaluation & Diagnosis
Pain with pressure on bottom of heel or arch Limping Foot Type: low vs. high arch, pronation
X-ray findings – Spur? Other abnormalities? Ultrasound Nerve Conduction Velocity studies to evaluate potential nerve problems MRI –rarely used. Mostly for chronic, unresponsive cases Plantar Fasciitis Treatment
Mechanical – treat the cause Anti-inflammatory – treat the pain Neither done in isolation Plantar Corticosteroid injections Fasciitis Taping (Low Dye) Treatment Running shoes Orthotics What I Dry Needling learned in Plantar fasciotomy training Plantar Fasciitis Treatment
Stretching, shoe modifications, avoid walking barefoot
Icing and rest
Night or resting splint
Supplemental arch support (OTC vs. custom orthotics)
Anti-inflammatory medication
Steroid injections
If conservative measures fail, surgery is an option Plantar Fasciitis Treatment What I do now
If there is any burning, tingling, numbness or sharp shooting pain worse at night I order NCV, EMG.
If there is any HX of claudication, rest pain or diminished pulses we schedule a PAD exam.
Bilateral digital x-rays to r/o stress fracture, tumor or other osseous abnormalities. When I see heel spurs plantar or retrocalcaneal I suspect a tight posterior muscle group.
Ultrasound exam and injection if the pain level warrants it and the patient is okay with needles.
If no shot then diclofenac gel 4 grams topically to heel qid
Low Dye strapping and/or Swedo brace.
Measure for Saucony stability shoes Plantar Fasciitis Treatment What I do now
Muscle strength testing including heel raise (PTTD)
Check for Tinel’s and Valleix's sign to R/O tarsal tunnel
Check for equinus if there is less than 10 degrees of dorsiflexion an Equinus Brace is dispensed.
After two weeks in the Equinus Brace stability shoes are dispensed
After two weeks in stability shoes and four weeks in EQ brace OTC orthotics are dispensed
At this point 90% of patient have a pain level of 2/10 or less. If pain is still significant a repeat injection or 4 weeks of meloxicam Other options for heel pain
Over 90% of heel pain patients respond to initial therapies within a relatively short period of time For unresponsive cases, options include: Minimally invasive procedures like ESWT (Extracorporeal Shock Wave Therapy) Autologous Platelet Concentrate (APC) injection Surgical procedures, open or endoscopic Cryosurgery Radiofrequency techniques Low Dye Strapping CPT 29540 Low Dye Strapping CPT 29540 Low Dye Strapping CPT 29540 Amis – Frontiers in Surgery 2016 The Split Second Effect: The Mechanism of How Equinus Can Damage the Human Foot and Ankle
"We are awakening to a new era of understanding the mechanics and function of the human foot and ankle. There is a simple, singular, usually silent, and remote cause for the majority of non- traumatic acquired foot and ankle pathology, and mechanically, it creates cumulative damage to the foot and ankle through leveraged forces. In short and in this author’s opinion, equinus is the primary mechanical common denominator that leads to the majority of acquired non-traumatic foot and ankle problems by indirect leveraged means as well as direct forces along the posterior/plantar chain. There can be no more room for the James Amis, MD standard thinking that these resultant foot and ankle problems arise just because we are getting older or we are obese or they are just random, or that an equinus contracture is only a part of the equation. Equinus is the equation." Silfverskiöld Exam position hindfoot in supination
examination technique Dayton et al. JFAS 2017 Experimental Comparison of the Clinical Measurement of Ankle Joint Dorsiflexion and Radiographic Tibiotalar Position
“Motion of the foot between the neutral and supinated positions introduced an additional source of potential error from the measurement technique when using the neutral position as the standard, which has been recommended in the past. We recommend a supinated foot position as a more reliable foot position for measuring the clinical ankle joint range of motion and propose it as a potential standard.” Liu & Xie HSSJ 2016 Association between Achilles tightness and lower extremity injury in children
page 033 Hill JAPMA 1995 Ankle equinus. Prevalence and linkage to common foot pathology
“The podiatric “Gastrocsoleus physician stretching was should look found to be an beyond the effective specific modality in complaint to treating a wide diagnose the range of underlying podiatric cause. complaints Frequently, where ankle ankle equinus equinus is an deformity will underlying be at the root of etiologic factor.” the patient’s foot problem.”
page 034 Hill JAPMA 1995 Ankle equinus. Prevalence and linkage to common foot pathology
“Treating apparent biomechanical problems that have an underlying equinus deformity with rigid functional orthoses is a major reason for unsuccessful orthotic treatment.”
“Equinus patients who receive orthoses as their sole treatment may not be capable of accepting orthotic control.”
“A rigid orthotic will prevent the foot from pronating. The result is arch irritation from excess friction against orthoses.” Equinus You are not paying enough attention!
Root et al “The worst foot in the world is the one with the fully compensated equinus deformity.”
Johnson and Christensen “Equinus deformity is the most profound causal agent in foot pathomechanics and is frequently linked to common foot pathology.” Hill “Equinus deformity is extremely prevalent, and it appears to be a primary causal agent in a significant proportion of foot pathology.”
page 036 Amis Foot Ankle Clin N Am 2014 The Gastrocnemius: A New Paradigm for the Human Foot and Ankle
“It has been postulated that epidemiologic factors, such as obesity, sedentary life style, medical comorbities, shoe wear, concrete floors, advanced age, female gender, and overuse issues, to name a few, are responsible for a variety of foot and ankle pathology. Although these factors might consistently coexist with a variety of foot and ankle problems and seem to have a causal relationship, it is my assertion that they have little if any direct relationship.” Amis Foot Ankle Clin N Am 2014 The Gastrocnemius: A New Paradigm for the Human Foot and Ankle
“The singular and real association of each of these epidemiologic factors is a contracture of the gastrocnemius muscle, which is camouflaged in this list. Most every other cause of these foot and ankle problems is likely mediated by contributing to the degree and/or rate of an already contracting gastrocnemius. These problems promote gastrocnemius tightness, which in time causes incremental damage to the foot and/or ankle.” Conditions Associated with Equinus Documented in the Literature • Heel Spur Syndrome/Plantar Fasciitis • 1st Ray Hypermobility
• Achilles Tendinopathy • Adult Pes Plano Valgus
• Posterior Tibial Tendon Dysfunction • Hallux Limitus
• Diabetic Foot Ulcers • Sesamoiditis
• Charcot Neuropathy • Lateral Column Syndrome/Foot Pain
• Metatarsalgia • Freiberg’s Infarction
• Morton’s Neuroma • Forefoot Callus
• Lesser MPJ pathologies – PDS, Capsulitis • Iliotibial Band Syndrome
• Hallux Valgus • Medial Tibial Stress Syndrome/Shin Splints
• Hammer Digit Syndrome • Patellofemoral Syndrome
• Ankle Fracture/Sprains • Chronic Ankle Instability
• Sever’s Disease • Tibial Stress Fractures
• Pediatric Flatfoot Deformity • Osteoarthritis Forefoot/Midfoot
• Poor Balance/Fall Risk Elderly • Muscle Strains
• Low Back Pain • Genu Recurvatum
• Ankle Arthritis • Arch Pain
• STJ Arthritis • Anterior Compartment Syndrome
• Forefoot Nerve Entrapment Johnson & Christensen – JAFAS 2005 Biomechanics of the First Ray Part V: The Effect of Equinus Deformity
“In clinical practice, the early destructive influence of equinus is often not appreciated. Instead, we are usually faced with the end result of equinus effects…” Johnson & Christensen – JAFAS 2005 Biomechanics of the First Ray Part V: The Effect of Equinus Deformity
“The authors strongly recommend careful clinical assessment and appropriate treatment of equinus in patients with biomechanical deformities affecting the first ray and midfoot.” Cheung et al. Clinical Biomechanics 2006 Effect of Achilles tendon loading on plantar fascia tension in the standing foot
page 042 Amis Frontiers in Surgery 2016 The Split Second Effect: The Mechanism of How Equinus Can Damage the Human Foot and Ankle
Split Second Effect – Ankle Joint Dorsiflexion
1. Starts the last ½ of midstance when swing phase foot starts to pass the stance foot 2. Ends as stance heel lifts just prior to 3rd Rocker beginning 3. Lasts approximately 120ms (1/10th second) 4. Leveraged & direct forces act upon foot & ankle or “start up” gait (limping) develops 5. “Start up” limp gait ⇒ Rest & lack of calf tension ⇒ Worsen calf tightness (Law of Davis) 6. 1000’s steps/per day over period of years ⇒ “occult, unrecognized, overuse of imbalance” ⇒ damage to foot & ankle Schneider et al – JFAS 2018 ACFAS Clinical Consensus Statement American College of Foot and Ankle Surgeons Clinical Consensus Statement: Diagnosis and Treatment of Adult Acquired Infracalcaneal Heel Pain
Consensus Statement: The panel reached consensus that the statement “Stretching is safe and effective in the treatment of plantar fasciitis” was appropriate.”
“Tight hamstrings and equinus are common in patients with plantar fasciitis. Treatment of equinus is important for all stages of plantar fasciitis.”
“The consensus of the panel is that stretching is extremely important in the treatment of plantar fasciitis. The type of stretching protocol (home stretching, night splint, or physical therapy) will vary according to the severity of the equinus and patient preference. No consensus was reached regarding the type of stretching needed. However, the panel agreed that more aggressive stretching would be preferred.” • Compliance – not stretching long enough daily (>30 minutes/day) • Lack of follow though – minimum of 6 weeks • Improper stretching technique – heel off ground, knee bent or not in full extension, STJ not in supination
Why manual stretching fails Manual stretching mistakes
page 046 Manual stretching mistakes
page 047 Why night splints fail
page 048 Why night splints fail
page 049 ideal equinus bracing concepts
01 02 03
Controllable ankle Engage Windlass lock knee into mechanism to supinate the joint dorsiflexion – STJ creating DF primarily full extension prevent over in the hindfoot and not in stretching and allow the midfoot, external for precision of rotation of the tibia allowing for full knee treatment extension via the “screw home mechanism” controllable stretch in above the knee hinges supination
page 050 The Equinus Brace™
page 051 DeHeer’s Recommendations Conservative Equinus Management
1 hour/day seated upright to also 0 stretch 1 hamstrings Stretch both legs at the same time if both have equinus deformity 02
Check monthly until above +5°, then 0 employ a maintenance therapy 3 program
page 052 Brian K. Bailey, DPM, MS Podiatric Physician & Surgeon Ashland, KY (606) 324-FOOT (3668) http://www.pandoracats.com/BMSP C/BMSPCmain.html Thank you for coming today!