76 Plantar Heel Pain (Dikis 2024).pdf

1 Etiology, Clinical Presentation & Differential Diagnoses Etiology Heel pain Perhaps the most common presenting complaint in F&A office setting Includes both posterior and plantar heel pain Majority plantar fasciitis 4 Etiology What is subcalcaneal heel pain? Plantar aspect of the heel Traumatic ve...

1 Etiology, Clinical Presentation & Differential Diagnoses Etiology Heel pain Perhaps the most common presenting complaint in F&A office setting Includes both posterior and plantar heel pain Majority plantar fasciitis 4 Etiology What is subcalcaneal heel pain? Plantar aspect of the heel Traumatic versus atraumatic 5 Etiology Repetitive traction Overuse Pronation Equinus Change in activity Increased body weight? Systemic/Rheumatologic conditions 6 Clinical Presentation: History Subcalcaneal Plantar heel pain Sharp, aching Post-static dyskinesia Worse with activity, end of day Duration Change in activity? Occupation? 7 Clinical Presentation: Exam Pain to palpation Side-to-side or transverse compression of calcaneus Silfverskiold exam Tinel’s sign Increased warmth? Edema? Ecchymosis, palpable dell or deficit 8 Clinical Presentation: Imaging X-rays Ultrasound MRI 9 Differential Diagnoses Plantar fasciitis Plantar fascial rupture Tarsal tunnel syndrome Baxter’s neuritis S1 radiculopathy Infracalcaneal bursitis Chronic exertional compartment syndrome Infection Tendinitis Contusion / Stress fracture 10 Plantar Fasciitis Most common cause of plantar heel pain “Heel spur syndrome” Can be present with or without spur formation High percentage of population with asymptomatic spur Most common findings: Post-static dyskinesia Change in activity Overuse / obesity 11 Plantar Fasciitis Thought to be an issue of increased traction on the calcaneus with eliciting of the Windlass mechanism during gait Some anatomic studies suggest that the spur is actually dorsal to the plantar fascia FDB or abductor hallucis origin 12 Plantar Fasciitis…or is it? Fasciitis or fasciosis? Lemont et al (2003) histologically examined 50 heel spur resection samples and found that there was no evidence of inflammation present Note: findings were not stratified by age, sex, or symptom duration Caution with interpretation of findings and application to treatment of heel pain 13 Plantar Fascia Rupture Partial or complete rupture of the plantar fascia Acute Acute-on-chronic Limited research to assist in guiding therapy 14 Tarsal Tunnel Syndrome Pain to plantar foot and medial ankle Compression of the tibial nerve or one of its branches Most often idiopathic Plantar fasciitis often concomitant condition Covered by Dr. E. Nelson 15 Tarsal Tunnel Syndrome Positive Tinel’s on exam NCS/EMG may help in differentiating from other causes of plantar heel pain 16 Baxter’s Neuritis “Distal tarsal tunnel syndrome” Dr. Donald Baxter first described nerve entrapment syndrome as a possible cause of chronic heel pain in 1984 First branch lateral plantar nerve Medial: Abductor hallucis and quadratus plantae Plantar: Flexor digitorum and quadratus plantae Innervates abductor digiti minimi muscle 17 Baxter’s Neuritis Symptoms specific to Baxter’s neuritis: Pain with increased activity Lack of classic post-static dyskinesia Plantar-lateral paresthesia Pain to palpation along the medial heel, along course of the nerve MRI will demonstrate: Evidence of atrophy of the abductor digiti minimi, including increased water signal and fibrofatty changes 18 When you hear hoofbeats… …think horses, not zebras. Infracalcaneal bursitis Infection Chronic exertional compartment syndrome Contusion / Stress fracture Bone tumors Systemic conditions (RA, ankylosing spondylitis, IBD) 19 Infracalcaneal Bursitis Bursa does not normally exist at the plantar surface of the calcaneus Adventitial bursae may form, but this is exceedingly rare Focal pain to the central and slightly posterior plantar heel 20 Chronic Exertional Compartment Syndrome Transient, symptomatic pressure increase within a myofascial compartment that is precipitated by exercise and subsides with cessation of athletic activity Medial compartment appears most susceptible: Abductor hallucis and flexor hallucis brevis muscles Medial planter nerve 21 Chronic Exertional Compartment Syndrome Cramping pain and tightness in the medial arch Pain on palpation of abductor hallucis Pain may be preceded or followed by tingling or numbness May mimic classic plantar fasciitis pain when the medial compartment of the foot is involved 22 Infection Hematogenous osteomyelitis Abrupt onset of increasing pain and tenderness Erythema, edema, increased warmth Most common in children Fever Elevated acute phase reactants Erythrocyte sedimentation rate C-reactive protein Leukocytosis 23 Tendinitis Can be confused with… Achilles tendinitis Continuation of fibers Tibialis posterior tendinitis Physical exam typically will quickly offer needed information to differentiate 24 Contusion / Stress Fracture History of trauma “Stone bruise” Pain with transverse compression of the body of the calcaneus Positive squeeze test Symptoms worsen with activity Recent change in activity 25 2 Nonsurgical Treatment Nonsurgical Treatments Inflammation Ice NSAIDs PO Local injection Iontophoresis (PT) Platelet-Rich Plasma (PRP)? 27 Platelet-Rich Plasma (PRP) Biologic therapies provide many different cellular components, growth factors, and proteins to restore normal tissue biology Superconcentrated portion of plasma of which the quantity of platelets are greater than baseline levels Contributes to influx of various growth factors and cytokines, promoting a healing cascade and regenerative effect 28 PRP literature rol Depo-Med r e v o P R fP with use o ve study ti m c r e te p s tr o r o p h ds FAI 2014; oth long an b in s lt u s e Improved r Orthopedics 20 16 No difference in results with us e of PRP and corticosteroids ; both improve d over use of N SS Medicine 2017; meta-analysis No difference in overall outcomes with use of PRP versus corticosteroid 29 Nonsurgical Treatments Support / Biomechanics OTC orthotics Physical Therapy Night splint Stretching regimen Astym / Dry needling Taping 30 Nonsurgical Treatment Patient education Plantar fasciitis is a condition that we often aim to manage, but don’t cure Recurrence is common if some degree of maintenance is not performed 31 Nonsurgical Treatments Up to 10% of patients, no matter how they are treated, eventually require surgical intervention Bilateral symptoms Pain present at least 1 year before presentation 32 3 Surgical Treatment Surgical Treatment Given the high rate of success with conservative therapies for plantar heel pain, we should exhaust non-operative measures prior to considering surgical intervention 6 months 34 Surgical Treatment Neurolysis Tarsal tunnel release 2 1 0 /. %*, # " + * ) ( $ # ' " & !"#$% Heel spur resection Plantar fasciotomy Open In-step EPF 35 Neurolysis Release of first branch of lateral plantar nerve (Baxter’s nerve) Concomitant release of plantar fascia or spur excision reported Traditionally with high satisfaction rates reported 36 Neurolysis Technique Oblique incision Fascia overlying abductor hallucis released Medial plantar fasciotomy Evaluation of neurovascular bundle and release of adhesions as needed 37 Neurolysis Tarsal tunnel Review lecture by Dr. E. Nelson Increasingly popular to include as component of plantar fascial release NCS/EMG rarely obtained Performed based on clinical suspicion 38 Heel Spur Resection Classic heel spur operation described by DuVries in 1957 Open and percutaneous approaches available Studies demonstrate no difference in outcomes with fasciotomy versus resection 39 Heel Spur Resection: Open Technique Incision placement designed to avoid larger branches of medial calcaneal nerve Identify fascial plane 40 Heel Spur Resection: Open Technique Fascia overlying abductor hallucis and plantar fascia identified. Fascial attachments to the calcaneus are incised Prominent spur can now be removed Fascial defect is repaired 41 Plantar Fasciotomy Three main approaches: 1. Open fasciotomy 2. In-step fasciotomy 3. Endoscopic plantar fasciotomy (EPF) 42 Plantar Fasciotomy: Open Approach Medial approach Offers great visualization Option for spur resection Increased risk to local neurovascular structures and higher rate of hematoma formation due to extent of dissection Traditionally longer recovery period 43 Plantar Fasciotomy: In-Step Designed to decrease likelihood of local nerve damage compared to open Smaller incision, less scarring Direct visualization obtained 44 Plantar Fasciotomy: In-Step 2- to 3-cm incision is placed over the prominent fascial band, just distal to the fat pad of the heel. Incision deepened with sharp dissection until the plantar fascia is reached. Once the fascia has been reached, a self-retaining retractor is inserted. With the patient's toes held in extension, the medial fascial band is severed. A small gauze bandage is applied and patient is allowed to begin immediate weightbearing. 45 Plantar Fasciotomy: In-Step 46 Plantar Fasciotomy: EPF Direct visualization utilizing endoscope Resection of medial third to half of fascia 47 Plantar Fasciotomy: EPF Advantages: Quick recovery Great visualization Disadvantages: Cost Unable to perform spur resection 48 Plantar Fasciotomy: EPF Several clinical trials reported EPF results with excellent relief of pain, with patient satisfaction from 60% to 80% and low complication rates 49 Additional Option: Radiofrequency Ablation (RFA) Microdebridement method to achieve localized destruction of dystrophic and fibrotic tissue with minimal surrounding tissue damage Focused radiofrequency energy, not heat, to excite electrolytes in a saline environment and ultimately lead to ability to break molecular bonds at a relatively low temperature 50 4 Complications Complications: Nerve Damage Best way to address complications is to avoid them in the first place! Proper diagnosis and patient selection Complications are infrequent and usually temporary Lateral column destabilization Nerve injury Painful scar formation Calcaneal fracture 52 Complications: Nerve Damage Lateral column destabilization Symptoms may include lateral column pain, sinus tarsitis, medial arch pain and fatigue, metatarsalgia and strain along the lesser tarsus Structures will typically adjust and accommodate with time Manage biomechanical disturbances Orthotics PT NSAIDs 53 Complications: Nerve Damage Painful scar formation Incision placement and anatomic dissection Relaxed skin tension lines Avoid unnecessary dissection of subcutaneous tissue Nerve Injury Baxter’s nerve May course proximally enough that it is at risk during plantar fasciotomy surgery 54 Complications: Nerve Damage Calcaneal fracture Stress riser created with spur excision Obtain x-rays, treat as indicated 55 Summary Up to 90% of patients will be successfully managed with wellexecuted nonsurgical care Consider possible “zebras” before proceeding with surgical intervention in a patient with recalcitrant heel pain Plantar fasciotomy most common procedure performed today Consider the role of ankle equinus and treat as indicated Primary gastrocnemius recession? Complications are rare but must be appropriately addressed to avoid long-term morbidity 56 References 1. Campillo-Recio et al. “Two-Portal Endoscopic Plantar Fascia Release:Step-by-Step Surgical Technique” Arthroscopy Techniques, Vol 10, No 1 (January), 2021: pp e15-e20. 2. Debus et al. “Rupture of plantar fascia: Current standard of therapy A systematic literature review” Foot and Ankle Surgery 26 (2020) 358–362 3. Lemont et al. “Plantar Fasciitis: A Degenerative Process (Fasciosis) Without Inflammation” J Am Podiatr Med Assoc (2003) 93 (3): 234–237. 4. McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery. 3rd Ed. Edited by Alan S. Banks, DPM, Michael S. Downey, DPM, Dennis E. Martin, DPM, and Stephen J. Miller, DPM. 2,304 pages, illustrated. Wolters Kluwer/Lippincott Williams & Wilkins Health, Philadelphia 2013. 5. S. Nelson. “Tarsal Tunnel Syndrome” Clin Podiatr Med Surg 38 (2021) 131–141. 6. Ng et al. “Biologics in the Treatment of Plantar Fasciitis” Clin in Pod Med Surg 2021; 38 (2); 245259. 7. K. Smith. “Heel Surgery (Plantar Fascial Release)”, PowerPoint 2020. Courtesy of Des Moines University. 57 Thanks! Copyright Notice: This presentation may contain copyrighted material used for educational purposes under the guidelines of Fair Use and the TEACH Act. It is intended only for use by students enrolled in this course. Reproduction or distribution is prohibited. Unauthorized use is a violation of the DMU Integrity Code and may also violate federal copyright protection laws. 58 Credits Special thanks to all the people who made and released these awesome resources for free: Presentation template by SlidesCarnival Photographs by Unsplash 59