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Painful heel
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- 2. • In 1922,Stiell – “painful heel appears to be a condition which is seldom efficiently treated, for the simple reason that the causation is not exactly diagnosed.” • 1965… Lapidus and Guidotti – “the name of painful heel is used deliberately in preference to any other more precise etiological diagnosis, since the cause of this definite clinical entity still remains unknown.” • Now, nearly 50 years later, – we still do not know the precise, inclusive cause of pain beneath the anteromedial prominence of the calcaneal tuberosity • A variety of other causes of heel pain are better understood, – such as heel cord tendinitis, – retrocalcaneal bursitis, – peroneal, posterior tibial, and FHL tendinitis. • However, the entity remains enigmatic and often frustrating for both physician and patient.
- 3. • the twomost common diagnoses considered in the first part of the twentieth century, that is, gonorrhea and tuberculosis, have been minimized. • the differential diagnosis of idiopathic heel pain 1. rheumatoid arthritis 2. ankylosing spondylitis 3. Reiter syndrome 4. Osteoarthritis • especially in patients with diabetes deep soft tissue abscess • In men < 40y with bilateral painful heels AS and Reiter syndrome • Women with bilateral symptoms RA • more than 2 million patients are treated for plantar fasciitis every year and estimated the cost of treatment in 2007 as ranging from $192 to $376 million.
- 5. ETIOLOGY • The exactcause of painful heel is uncertain. 1. degenerative changes with increasing age are the most constant findings in the elastic adipose tissue of the heel pad. – Aging also brings about a gradual reduction in collagen and water content, as well as elastic fibrous tissue. – This degenerative process in the calcaneal heel pad can account in part for soreness under the heel. 2. the windlass mechanism of the plantar fascia as the toes are dorsiflexed. – The plantar fascia • originates from the anteromedial plantar aspect of the calcaneal tuberosity • inserts through several slips into the plantar plates of the metatarsophalangeal joints, the flexor tendon sheaths, and the bases of the proximal phalanges of the digits –under constant traction as it is pulled distally around the drum of the windlass (metatarsal heads). – This tightening of the cable, elevates the longitudinal arch and in so doing places traction on the origin of the plantar fascia
- 7. ETIOLOGY 3. “tennis heel” •The most dense, unyielding section of the plantar aponeurosis originates from the location on the tuberosity of the calcaneus where the most common point of local tenderness is found during physical examination. • Compare this to “tennis elbow.” • undergoing microscopic tears and cystic degeneration with aging and repeated trauma, repetitive traction in the origin of the plantar fascia and the flexor digitorum brevis immediately beneath the plantar fascia
- 8. ETIOLOGY 4. entrapment ofthe first branch of the lateral plantar nerve to the abductor digiti minimi • passes between the deep surface of the FDB and the “heel spur” and adjacent quadratus plantae muscle. • This small nerve and accompanying vessels with one or more periosteal branches pass deep in this area of the heel as this nerve approaches the abductor digiti minimi muscle, which it innervates. • a few patients (1% to 2%) have a neurogenic pathological condition associated with painful heel syndrome. • differentiated neurogenic causes from others by – localizing tenderness along the lateral plantar nerve inferior to the flexor retinaculum as the nerve approaches the calcaneal tuberosity. – Patients with plantar fasciitis describe, tenderness only at the medial tubercle – but patients with a neurogenic component have tenderness all along this nerve. • release of the deep fascial edge of the abductor hallucis muscle.
- 9. CLINICAL FINDINGS • between40 and 70 years of age • male • quite active • unilateral symptoms • a normally arched foot • Obesity is a predisposing factor, and the symptoms are even more difficult to control when a patient is overweight. • It is uncertain if pes planus or pes cavus predisposes to this condition. • In a study of U.S. military personnel, Scher et al. – a slightly higher incidence in women. – Female sex, black race, and increasing age were among the risk factors they identified for plantar fasciitis.
- 10. • The majorcomplaint is pain – beneath the heel – worse on rising in the morning or after sitting for a while. – After a few steps the pain diminishes – the patient is reasonably comfortable during the day – Toward the end of the day, the discomfort becomes more of an aching that is relieved by absence of weight bearing. • The most common physical finding – localized tenderness at the inferomedial aspect of the calcaneal tuberosity. – mild swelling and erythema – The duration of symptoms varies from a few weeks to several months or even years.
- 11. RADIOGRAPHIC FINDINGS • acalcaneal spur in about 50% of patients, but the exact significance of this finding is uncertain. • Although the diagnosis is a clinical one and basically one of exclusion, a bone scan may be of some help. – In a study of 36 patients with the diagnosis of unilateral painful heel, scans were positive in all but one of the symptomatic patients. – The anteroinferior medial aspect of the calcaneus demonstrated the most isotope uptake. – Bone scanning has been helpful in patients with equivocal diagnoses of painful heel to document the clinical impression when symptoms are recalcitrant to routine treatment over an extended period or to rule out stress fracture.
- 12. RADIOGRAPHIC FINDINGS • MRImay be helpful in the evaluation of heel pain. – In a review of 50 patients with persistent heel pain, MRI confirmed the diagnosis in 38 (76%). – Although it rarely changes the management of patients with typical symptoms of plantar fasciitis, in patients with atypical heel pain MRI may demonstrate other pathological processes such as plantar fascia tearing, calcaneal edema, or arteriovenous malformation. • Electromyography of the abductor digiti minimi muscle may be helpful in the diagnosis if symptoms have been present for several weeks or months and when nerve entrapment is suggested. • The tibial nerve can be carefully palpated beneath the flexor retinaculum by percussing it gently and rolling it back and forth beneath the examining fingers. • If the tenderness at this location is significant, release of the nerves to the abductor digiti minimi alone may not relieve the symptoms, and partial medial plantar fasciotomy may be required
- 13. TREATMENT • Rarely doesa patient with a painful heel require surgery to relieve the symptoms.
- 20. TREATMENT • A prospective,randomized controlled trial comparing intralesional autologous blood injection with corticosteroid injection – found that the blood injection was effective in reducing pain and tenderness – but that corticosteroid was superior in onset of relief. • Reports in the literature indicate that more than 90% of patients with plantar fasciitis can be successfully treated nonoperatively. • High-energy extracorporeal shock wave treatment has been reported to be effective for recalcitrant plantar fasciitis, but there are no large randomized studies confirming its benefits.
- 21. TREATMENT • In somepatients, symptoms persist over an extended time despite all forms of conservative management. • If the patient is made fully aware of the possibility that no improvement may occur after surgery, then surgery can be recommended.
- 22. TREATMENT • Recommended proceduresinclude (1) elevation of the entire heel pad through a horseshoe incision around the hindfoot, with release of all soft tissue origins from the anterior aspect of the calcaneal tuberosity (2) neurolysis of a single nerve (3) osteotomy of the calcaneus (4) excision of the medial inferior tuberosity of the calcaneus (5) simple drilling of multiple holes in the calcaneus in a “decompressing operation.” • If the procedure chosen does not involve removing the calcaneal spur, if present, the patient must be informed of this before surgery to avoid confusion, disappointment, and possibly a poor result from a psychological perspective alone.
- 23. • endoscopy forplantar fascia release based on limited release of the central cord of the fascia. – an effective procedure with reproducible results, a low complication rate, and little risk of iatrogenic nerve injury. • We have no experience with endoscopic technique and prefer open plantar fascia and nerve release. • Most patients with heel pain syndrome who ultimately require surgery have some evidence of entrapment of the first branch of the lateral plantar nerve. • For these few patients, the procedure which includes 1. decompression of the first branch of the lateral plantar nerve 2. removal of the insertion of a portion of the plantar fascia 3. removal of the heel spur, – seems to be more of a complete procedure than a simple incision of the plantar fascia with the endoscopic method.
- 24. Incision is madeover first branch of lateral plantar nerve Superficial fascia of abductor hallucis muscle is released Abductor hallucis muscle is reflected proximally Abductor hallucis muscle is retracted distally PLANTAR FASCIA AND NERVE RELEASE
- 26. Resection of smallmedial portion of plantar fascia Resect a 2 to 3 × 4-mm rectangle of medial plantar fascia. An entire plantar fasciotomy may be performed in some nonathletic patients who have pain throughout the entire insertion of the plantar fascia medially and laterally.
- 27. • If alarge spur is present preoperatively and is thought to contribute to symptoms, resect the spur by gently reflecting the flexor digitorum brevis off the exostosis. • Take care not to damage the first branch of the lateral plantar nerve that lies just superior to the spur.
- 28. POSTOPERATIVE CARE • non–weightbearing for 2 weeks after surgery. • The sutures are then removed • gradual weight bearing to tolerance is begun. • Resumption of heel cord stretching and increased activity are encouraged.