Conquering Conservative Care For Heel Pain
Heel pain is certainly one of the most ubiquitous complaints among our patients. Plantar heel pain is by far the most common location with proximal plantar fasciitis (heel spur syndrome) accounting for the majority of cases. Proximal plantar fasciitis, otherwise referred to as heel spur syndrome, is common in any podiatric practice and is certainly the most frequently encountered etiology of heel pain. Plantar fasciitis has been reported to comprise up to 10 percent of all foot and ankle injuries. The clinical presentation consists of insidious onset plantar or plantar/medial heel pain. In most cases, patients will note that their pain is worse in the morning and after any periods of nonweightbearing rest. This phenomenon has been referred to as post–static dyskinesia. Quite often, there is an overuse history or increase in weight, although acute onset traumatic causes are not uncommon. Inappropriate shoes with an unstable (excessively flexible) shank may be a contributing factor as well. During the physical examination, patients will have pain upon palpation of the plantar or plantar/medial heel at the junction of the medial band of the plantar fascia and the medial calcaneal tubercle. I will also squeeze the heel side to side and check for pain. If the patient does have discomfort, one must consider the possibility of a calcaneal stress fracture. Ankle equinus is perhaps the most common physical finding and is considered by most to be the most significant etiologic factor. One must rule out other biomechanical factors including cavus foot structure, excessive subtalar/midtarsal joint pronation during gait and limb length inequality. Excessive subtalar joint pronation alone cannot be responsible for plantar fascial strain. Longitudinal midtarsal joint supination with dorsiflexion of the first ray is more of a direct influence upon the plantar fascia. Radiographic findings may demonstrate the presence of a calcaneal spur. This represents a form of enthesiopathy and is usually not responsible for the symptoms. However, in some cases, the plantar heel fat pad has atrophied or displaced, resulting in reduced shock absorption and protection for the calcaneus. In these cases, a heel spur may be the cause of pain and may require horseshoe padding or some other type of orthotic modification to provide more heel cushion. In many cases of heel spur syndrome, the radiographs are completely unremarkable. Offering A Successful Regimen For Conservative Management Conservative management of heel spur syndrome includes Achilles and fascial stretching, physical therapy, an over-the-counter or custom orthosis and injectable or oral antiinflammatory medications. When injecting a corticosteroid, I favor the plantar approach and prefer to deliver the local anesthetic and steroid separately. A low-dye taping is very useful, especially following an injection of corticosteroids. I believe that deep massage is the most essential element when prescribing physical therapy. A plantar fascial night splint may be helpful, especially in more difficult cases. In my experience, greater than 65 percent of patients have an excellent outcome within six months following this regimen. If the patient is not improving within the first few weeks, I frequently will perform a diagnostic test, such as magnetic resonance imaging (MRI), to exclude the possibility of another etiology. How To Maximize Outcomes With Orthotics I usually begin treatment with a prefabricated orthosis, which usually provides an excellent outcome. However, when initial care fails, I will proceed to use a custom functional orthotic device. Current research suggests that forefoot varus posting is not appropriate even in the presence of a forefoot varus or excessive subtalar joint pronation. In one study, wedges placed under the lateral forefoot decreased the strain upon the plantar fascia while wedges placed under the medial forefoot increased fascial strain. Any force that causes first ray dorsiflexion will result in midtarsal longitudinal axis supination and subsequent strain on the plantar fascia. When there is a forefoot varus, you should utilize a first ray cut-out to promote plantarflexion. When there is a forefoot valgus, a reverse Morton’s extension may be useful for maintaining the first ray in a plantarflexed position. Doug Richie, DPM has formulated a “Seal Beach Protocol” for the orthotic management of subcalcaneal pain. In cases of forefoot varus, this protocol calls for balancing the second through fifth metatarsals with a first ray cut–out. In cases of forefoot valgus, you would balance the first through fifth metatarsals with light filler between the balance platform with no first metatarsal cut–out. One of the final conservative measures that I may employ is immobilization. Four to six weeks of weightbearing immobilization has shown efficacy in some resistant cases. Presumably, the cast allows for complete rest of the region while facilitating a constant stretch of the Achilles tendon and plantar fascia. Getting Results In Resistant Heel Pain Cases With Shockwave Therapy When standard conservative care fails, extracorporeal shockwave therapy (ESWT) has been reportedly effective in 60 to 80 percent of patients with resistant proximal plantar fasciitis for greater than six months. Shockwaves are generated with either an electrohydraulic, electromagnetic or piezoelectric device and the patient receives anywhere between one and four treatments. The effect of the shockwave has been shown to stimulate neovascularization of previously non-viable, dysvascular scar tissue. Of the three known methods of shockwave generation, electrohydraulic is the most powerful and was the first FDA approved technology in the United States. I have experience utilizing the Ossatron and have had outstanding results after a single application within 12 weeks. In addition, I have had 50 percent success when treating Achilles insertional calcific tendinosis (AICT) with ESWT. I believe that ESWT has great promise in treating non-union fractures and Achilles tendinosis as well. There are no known contraindications to ESWT although one must be cautious about using the device with pregnant patients and those who have open growth plates, fractures, inflammatory arthritis, infection and/or a suspected neoplasm. What You Should Know About Other Emerging Modalities Some have also suggested using attenuated botulism toxin (Botox) to help manage proximal plantar fasciitis. The concept is that inflexibility of the plantar intrinsic muscles is part of the etiology. When a calcaneal spur is present, it is usually located at the origin of the flexor digitorum brevis and the abductor hallucis. When Botox is utilized, the plantar heel, abductor hallucis and flexor hallucis brevis are the injection sites. The effect of the medication reportedly lasts approximately six months with a resulting increase in flexibility of the plantar musculature. The early results are very promising. Keep in mind that Botox is not widely available for this condition as many of the initial studies are currently in progress. There is no solid evidence to support the efficacy of ultrasound treatments, magnetic insoles, low-intensity laser therapy or exposure to electron generating devices when it comes to managing proximal plantar fasciitis. Magnetic insoles have been frequently discussed during the past few years but their effectiveness is largely theoretical and anecdotal. Pertinent Pointers On Posterior Heel Pain Posterior heel pain is not uncommon and conservative management is generally more challenging. When treating pediatric patients between the ages of 7 to 13, keep in mind that an insidious onset of posterior heel pain is highly suggestive of Sever’s disease (calcaneal apophysitis). Sever’s disease usually responds well to reduced activity, icing, Achilles stretching and, in severe cases, immobilization. Achilles insertional calcific tendonosis (AICT) is one of the most severe causes of posterior heel pain and usually affects adults with ankle equinus. The history is significant for an insidious onset of pain, which is usually accompanied by an enlarging posterior heel prominence. Another possible contributing factor is shoe gear that produces direct irritation to the area. The etiology is chronic Achilles inflexibility with reduction of vascularity to the affected area. The resulting calcium deposition may be limited to the posterior heel or, in some cases, extend upward into the substance of the tendon itself. In my experience, the most severe cases occur in heavy individuals with significant hypertrophy of the gastrocnemius/soleus muscle and equinus. The lateral Harris-Beath and modified Harris-Beath radiographic views are usually diagnostic. Conservative management consists of dexamethasone iontophoresis, ice massage, friction massage, NSAIDs and a plantar fascia night splint. However, I have observed only 30 to 50 percent efficacy utilizing this regimen and many patients require surgical intervention. As I mentioned earlier, ESWT has shown some success in resistant cases of AICT. Case Study: A Patient With Two Years Of Posterior Heel Pain A 47-year-old male presents with a painful left posterior heel of two years’ duration. The pain has gradually been increasing and he experiences pain with exercise and especially after long periods of rest. He has seen several other physicians, has exhausted physical therapy, stretching, night splints, antiinflammatory medications and even underwent an extracorporeal shockwave therapy treatment. He was reluctant to consider a surgical option due to his busy schedule. His medical history is essentially unremarkable and he wears reasonable shoe gear. During the physical examination, the patient had pain upon palpation of his left posterior heel and there was evidence of bony exostosis on the posterior-central and posterior-lateral aspects of the calcaneus. The patient also had ankle equinus and a cavus foot. Lateral Harris-Beath and modified Harris-Beath radiographs confirmed the presence of calcaneal osteophytes. There was an increased calcaneal inclination that was consistent with a cavus foot structure. One concept I firmly believe in is considering the possibility of a somewhat unlikely diagnosis when standard care of a more common diagnosis fails. In this case, we considered the diagnosis of chronic gouty arthritis and placed the patient on a dose of oral colchicine. Within one week, the patient reported a 75 percent decrease in pain. Subsequent laboratory tests confirmed the presence of hyperurecemia. Key Insights On Managing Medial Calcaneal Neuromas When the clinical presentation of proximal plantar heel pain is proximal medial or when biomechanical management, such as a low-dye taping or and orthosis, is not effective, this is suggestive of a medial calcaneal neuroma. The medial calcaneal is the first branch of the posterior tibial nerve and descends along the central medial aspect of the calcaneus. One must carefully palpate the medial wall of the calcaneus in order to identify the location of the neuroma. A thickening in the skin that is painful to palpation is very suggestive of a lesion. Obtaining a MRI may be useful in confirming your diagnosis. Keep in mind that Baxter’s neuroma or neuritis associated with the first branch of the lateral plantar nerve is not as common and generally presents more plantarly and to the posterior aspect of the medial calcaneus. Historically, conservative management of medial calcaneal neuromas has consisted largely of corticosteroid injections. However, I favor the sclerosing effect of a 4% ETOH solution consisting of ETOH diluted in .5% Marcaine with epinephrine, as described by Dockery. One would perform the injection, which consists of .5 cc of the 4% ETOH solution, approximately 1 cm proximal to the location of the lesion. One may provide up to seven injections on a weekly basis without the fear of complications, which plague repeated corticosteroid injections. I have had a 60 percent success rate using the 4% ETOH solution compared to 30 percent with corticosteroid injections. Solutions For Common Differential Diagnoses In my experience, I have observed a significant number of patients who complain of lateral heel or lateral foot pain that has become problematic following an initial onset of plantar-medial heel pain. In most cases, this lateral heel pain is a calcaneal contusion (bruise) secondary to subtalar supinatory compensation during gait. As with any compensation, once you have resolved the primary etiology, the secondary problem generally resolves spontaneously and without any direct treatment. In my opinion, the calcaneal stress fracture is the most commonly encountered differential diagnosis for proximal plantar fasciitis. An overuse history is common and the initial symptoms may resemble proximal plantar fasciitis. As mentioned previously, the medial/lateral squeeze test is a useful means of clinical identification. Employing MRIs or bone scans is also effective in making an early diagnosis. Keep in mind that standard radiographs will be positive only three to four weeks after the initial onset of symptoms. Management consists of weightbearing immobilization for four to six weeks. I will utilize a CAM walker, which allows the patient to perform deep-water running exercises as an alternative activity. Final Notes Although we have discussed the most common types and causes of heel pain, there are several other possibilities. Practitioners must have knowledge of the different potential etiologies and consider them carefully with every patient. Due to the ubiquitous nature of proximal plantar fasciitis, it is easy to resign each case of plantar heel pain to this diagnosis. However, it is essential that we consider all possibilities and perform appropriate diagnostic testing when conservative measures are ineffective. Dr. Losito is a Professor at the Barry University School of Graduate Medical Sciences. He is the President of the American Academy of Podiatric Sports Medicine and is the Team Podiatrist for the Miami Heat. Editor’s Note: For related articles, see “Extracorporeal Shockwave Therapy: Hope Or Hype?” or “A Closer Look At Tarsal Tunnel Syndrome” in the November 2003 issue, or check out the archives at www.podiatrytoday.com.
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