Due to Medial Calcaneal Nerve Treatment of Painful Heels with 4% Alcohol Injection

“Dock” DOCKERY, DPM [email protected] Treatment of Painful Heels Due to Medial Calcaneal Nerve Treatment of Painful Heels with 4% Alcohol Injection

Dock Dockery, DPM, FACFAS

Fellow, American College of Foot & Ankle Surgeons; Fellow, American Society of Foot & Ankle Dermatology; Fellow, American College of Foot & Ankle Pediatrics; Fellow, American College of Foot & Ankle Orthopedics and Medicine; Board Certified, American Board of Foot & Ankle Surgery; Board Certified, American Board Podiatric Medicine; Author of:

- Color Atlas & Text of Forefoot Surgery (Mosby 1992); - Cutaneous Disorders of the Lower Extremity (WB Saunders 1997); - Color Atlas of Foot & Ankle Dermatology (Lippincott 1999); - Lower Extremity Soft Tissue & Cutaneous Plastic Surgery (Elsevier 2012) Chairman and Director of Scientific Affairs, International Foot & Ankle Foundation; Everett, Washington [email protected] Examination of Plantar Fascia – Medial Calcaneal Condyle

Direct Pressure to fascia Direct Pressure to fascia Insertion with Thumb Insertion with Finger Diagnosis of Heel Pain Inferior Calcaneal Bursitis Diagnosis of Heel Pain Retrocalcaneal Bursitis/AICT Diagnosis of Heel Pain Inferior Calcaneal Periostitis/Fracture

Pulling-Distraction causes increased discomfort Diagnosis of Heel Pain Piezogenic Papules

Insertion of PF

Dockery GL, Diana JL: Painful piezogenic papules. JAPA,1978;680(10):703-705. Diagnosis of Heel Pain Piezogenic Papules

P.T. Nerve, Tendon

Area of MCN

Insertion of PF Diagnosis of Heel Pain TARSAL TUNNEL SYNDROME A Cause of Heel Pain Heel pain accompanied by neuropathic features such as tingling, burning, or numbness may indicate tarsal tunnel syndrome, a compression neuropathy caused by entrapment of the posterior tibial nerve branches within the tunnel.

Aldridge T. Diagnosis of Heel Pain in Adults. Am Fam Physician, 2004, 70(2):332-338. Diagnosis of Heel Pain

Insertional Plantar Fasciitis

Insertional Plantar Fasciitis vs Medial Calcaneal Neuropathy Medial Calcaneal Nerve Pain Medial Calcaneal Nerve Pain Medial Calcaneal Nerve Pain Medial Calcaneal Nerve Pain 1st Branch of Lateral Plantar Nerve Pain (Baxter’s Neuritis)

Abductor Digiti Minimi

• Baxter DE, Thigpen CM: Heel Pain – operative results. Foot Ankle 5:16-25, 1984. • Baxter DE, Pfeffer GB. Treatment of chronic heel pain by surgical release of the first branch of the lateral plantar nerve. Clin Orthop Relat Res. 1992; (279):229-236. • Baxter DE. “Release of the Nerve to the Abductor Digiti Minimi” in Master Techniques in Orthopaedic Surgery of The Foot and Ankle, p 359, Lippincott Williams and Wilkins, Phila, PA, 2002. Treatment of Heel Pain Medial Calcaneal Nerve Pain My “Preferred Treatment”

Dilute solution (4%) of ethyl alcohol injected into medial calcaneal nerve region of heel.

Done once per week (or every 10 days) until symptoms resolve (up to seven injections) 4% Alcohol Injection Treatment of Painful Heels

4 % ALCOHOL SOLUTION:

48 cc of Local Anesthetic* *(0.5% bupivacaine w/ epinephrine) + 2 cc of Dehydrated Alcohol = 50 cc of 4% Sclerosing 4% Alcohol Injection Treatment of Painful Heels

48 cc of Local Anesthetic* *(0.5% bupivacaine w/ epinephrine) + 2 cc of Dehydrated Alcohol 4% Alcohol Injection Treatment of Painful Heels **IMPORTANT**

• Make a NEW label for the bottle to prevent accidental injection of the 4% Alcohol Sclerosing Solution! 4% Alcohol Injection Treatment of Painful Heels Add a NEW Label, 4% and Date Mixture Made 4% Alcohol Injection Treatment of Painful Heels 1. “This alcohol solution has a very high affinity for nerve tissue and it produces neuritis and Wallerian nerve degeneration (chemical neurolysis)” 2. May cause a fine thin fibrous scar when injected at the deep dermal layers.

Dockery GL: Evaluation and Treatment of Metatarsalgia and Keratotic Lesions, in Myerson M (ed): Foot and Ankle Disorders, W.B. Saunders. Phila., ch. 12, p.359-377, 2000. 4% Alcohol Injection Treatment of Painful Heels

INJECTION METHOD: • 0.5 cc (1/2 ml) of 4% Alcohol Solution • 27 gauge, 5/8 inch needle • Inject proximal to nerve pain • Repeat Weekly (5 - 10 days) – injections Minimum: 3 Maximum: 7 ICD-9 Diagnostic Codes: Prior to 2016

• 355.8 neuritis, peripheral • 355.9 nerve entrapment • 997.61 amputation neuroma • 956.4 nerve injury, skin/sensory • 956.9 nerve injury, unspecified • 729.5 pain, lower extremity ICD-10 Diagnostic Codes:

355.8--neuritis, peripheral 977.61--amputation neuroma G57.6 Lesion of plantar nerve Complication (s) (from) (of) amputation stump (surgical) (late) T87.9 G57.60 …… unspecified lower limb neuroma T87.30 G57.61 …… right lower limb 956.4--nerve injury, skin/sensory G57.62 …… left lower limb S94.3 Injury of cutaneous sensory nerve at ankle and G57.8 Other specified mononeuropathies of lower foot level limb S94.30 Injury of cutaneous sensory nerve at ankle G57.80 Other specified mononeuropathies of and foot level, unspecified leg unspecified lower limb S94.30XA …… initial encounter S94.30XD …… subsequent encounter G57.81 Other specified mononeuropathies of S94.30XS …… sequelae right lower limb S94.31 Injury of cutaneous sensory nerve at ankle G57.82 Other specified mononeuropathies of and foot level, right leg left lower limb S94.31XA …… initial encounter S94.31XD …… subsequent encounter 355.9--nerve entrapment S94.31XS …… sequelae Neuropathy, neuropathic S94.32 Injury of cutaneous sensory nerve at ankle entrapment G58.9 and foot level, left leg S94.32XA …… initial encounter S94.32XD …… subsequent encounter S94.32XS …… sequelae

And…. ICD-10 Diagnostic Codes:

956.9--nerve injury, unspecified S94.8 Injury of other nerves at ankle and foot 729.5--pain in lower extremity level M79.66 Pain in lower leg S94.8X Injury of other nerves at ankle M79.661 Pain in right lower leg and foot level M79.662 Pain in left lower leg M79.669 Pain in unspecified lower leg S94.8X1 Injury of other nerves at M79.67 Pain in foot and toes ankle and foot level, right leg M79.671 Pain in right foot S94.8X1A …… initial encounter M79.672 Pain in left foot S94.8X1D …… subsequent M79.673 Pain in unspecified foot encounter M79.674 Pain in right toe(s) S94.8X1S …… sequelae M79.675 Pain in left toe(s) S94.8X2 Injury of other nerves at ankle and M79.676 Pain in unspecified toe(s) foot level, left leg S94.8X2A …… initial encounter S94.8X2D …… subsequent encounter S94.8X2S …… sequelae S94.8X9 Injury of other nerves at ankle and foot level, unspecified leg S94.8X9A …… initial encounter S94.8X9D …… subsequent encounter S94.8X9S …… sequelae MEDIAL CALCANEAL NERVE ENTRAPMENT MEDIAL CALCANEAL NERVE ENTRAPMENT

Not All Heel Pain is Plantar Fasciitis or Insertional Fasciosis Dockery GL: Dilute Alcohol Injections for Nerve Conditions and Keratotic Lesions of the Foot. Podiatry Management. p.117-126, January 2004. 2018 CPT Codes • 64455: Injection(s), anesthetic agent and/or steroid, plantar common digital nerve (e.g. Morton’s Neuroma) • 64632: Destruction by Neurolytic Agent; plantar common digital nerve or peripheral nerve (i.e. alcohol)

• 64632 has a 10 day global and can be used instead of 64640. • Do not report 64632 and 64455 together References

• Dockery GL: Treatment of Intermetatarsal Neuromas with 4% Alcohol Sclerosing Injections. JFAS, 38 (6): 403-408, 1999.

• Masala S, Fanucci E, Ronconi P, et al: Treatment of intermetatarsal neuromas with 30% alcohol injections under US guide. Radiol Med (Torino) 2001; 102:370-373.

• Fanucci E, Masala S, Fabiano S, et al: Treatment of intermetatarsal Morton’s neuroma with 10% alcohol injection under US guide: a 10- month follow-up. Eur Radiol. 2003 Mar;14(3):514-8. • Hyer CF, Mehl LR, Block AJ, Vancourt RB: Treatment of Recalcitrant Intermetatarsal Neuromas with 4% Sclerosing Alcohol. JFAS, 44(4):287-291, 2005.[73% improved] • Mozena J, Clifford J: Efficacy of Chemical Neurolysis for Treatment of Interdigital Nerve Compression of the Foot. JAPMA 97(3):203-206, 2007. [74% w/ 5 or more inj = 74% improved] • Hughes RJ, Ali K, Jones H, Kendall S, Connell DA: Treatment of Morton’s Neuroma with Alcohol Injections Under Sonographic Guidance: Follow-up of 101 Cases. Am J. Roentgenology, 188:1535- 1539, 2007.[84% pain free/94% improved] Additional References • Alshami AM, Souvlis T and Coppieters MW: A review of plantar heel pain of neural origin: Differential diagnosis and management, Manual Therapy, (13)2:103-111, 2008. • Arenson DJ, Cosentino GL, Suran SM: The inferior calcaneal nerve. JAPA 70: 552, 1980. • Baxter DE, Thigpen CM: Heel Pain-operative results. Foot Ankle 5:16, 1984. • Baxter DE, Pfeffer GB: Treatment of chronic heel pain by surgical release of the first branch of the lateral plantar nerve. Clin Orthop 279: 229, 1992. • Baxter DE. “Release of the Nerve to the Abductor Digiti Minimi” in Master Techniques in Orthopaedic Surgery of The Foot and Ankle, ed by HB Kitaoka, p 359, Lippincott Williams and Wilkins, Philadelphia, 2002. • Dellon AL. Deciding when heel pain is of neural origin. J Foot Ankle Surg 40(5):341-5, 2001. • Dellon AL, Kim J, Spaulding CM. Variations in the origin of the medial calcaneal nerve. J Am Podiatr Med Assoc 92(2):97-101, 2002. • Dockery GL: Dilute Alcohol Injections for Nerve Conditions and Keratotic Lesions of the Foot. Podiatry Management. p.117-126, January 2004. • Lareau CR, et al. Plantar and medial heel pain: diagnosis and management. JAAOS. 22(6):372-80, 2014. • Panchbhavi VK. Plantar Heel Pain. Medscape Emedicine, Mar 2014. http://emedicine.medscape.com/article/1233178-overview • Rondhuis JJ, Huson A: The first branch of the lateral plantar nerve and heel pain. Acta Morphol Neerl Scand 24: 269-279, 1986. • Sammarco GJ, Helfrey RB: Surgical treatment of recalcitrant plantar fasciitis. Foot Ankle 17: 520, 1996. • Sarrafian SK: "Nerves" in Anatomy Of The Foot And Ankle, p 381, JB Lippincott, Philadelphia, PA, 1993. • Schon LC, Baxter DE. Heel pain syndrome and entrapment neuropathies about the foot and ankle. In: Operative Foot Surgery. Gould JS (ed). WB Saunders, Philadelphia, pp 192-208, 1994. • Young CC, et al. Treatment of plantar fasciitis. Am Fam Physician, 63(3):467-475, 2001.

Dock Dockery, DPM 4% Alcohol Injections for Heel Pain

THANK YOU!

[email protected]