How To Address Mechanically-Induced Subcalcaneal Pain

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Continuing Education Course #147 — November 2006

I am pleased to introduce the latest article, “How To Address Mechanically-Induced Subcalcaneal Pain,” in our CE series. This series, brought to you by the North American Center for Continuing Medical Education (NACCME), consists of complimentary CE activities that qualify for one continuing education contact hour (.1 CEU). Readers will not be required to pay a processing fee for this course.

Given the prevalence of plantar fasciitis, Paul R. Scherer, DPM, and Lori L. Waters, BSc, BEd, discuss the need for a better understanding of the different etiologies for heel pain and the respective terminology. They offer a closer look at mechanically-induced subcalcaneal pain and provide key insights on using orthotics to treat the condition based upon the literature and clinical experience.

At the end of this article, you’ll find a nine-question exam. Please mark your responses on the enclosed postcard and return it to NACCME. This course will be posted on Podiatry Today’s Web site (www.podiatrytoday.com) roughly one month after the publication date. I hope this CE series contributes to your clinical skills.

Sincerely,

Jeff A. Hall
Executive Editor
Podiatry Today

INSTRUCTIONS: Physicians may receive one continuing education contact hour (.1 CEU) by reading the article on pg. 78 and successfully answering the questions on pg. 82. Use the enclosed card provided to submit your answers or log on to www.podiatrytoday.com and respond via fax to (610) 560-0502.
ACCREDITATION: NACCME is approved by the Council on Podiatric Medical Education as a sponsor of continuing education in podiatric medicine.
DESIGNATION: This activity is approved for 1 continuing education contact hour or .1 CEU.
DISCLOSURE POLICY: All faculty participating in Continuing Education programs sponsored by NACCME are expected to disclose to the audience any real or apparent conflicts of interest related to the content of their presentation.
DISCLOSURE STATEMENTS: Dr. Scherer and Ms. Waters have disclosed that they have no significant financial relationship with any organization that could be perceived as a real or apparent conflict of interest in the context of the subject of their presentation.
GRADING: Answers to the CE exam will be graded by NACCME. Within 60 days, you will be advised that you have passed or failed the exam. A score of 70 percent or above will comprise a passing grade. A certificate will be awarded to participants who successfully complete the exam.
TARGET AUDIENCE: Podiatrists
RELEASE DATE: November 2006
EXPIRATION DATE: November 30, 2007
LEARNING OBJECTIVES: At the conclusion of this activity, participants should be able to:
• discuss key points of clarification as to why plantar fasciitis, heel spur syndrome and calcaneal bursitis may be inappropriate terms;
• list the symptoms that occur with mechanically-induced subcalcaneal (MSC) pain;
• discuss the key finding from Kogler’s work using a valgus wedge for those with a strain gauge in the plantar fascia;
• review pertinent conclusions from the recent studies by Roos and Landorf on using orthotics for plantar fasciitis; and
• discuss key considerations in maximizing orthotic treatment of MSC pain.
Sponsored by the North American Center for Continuing Medical Education.

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Here one can see a periostitis. The authors suggest that mechanically-induced subcalcaneal pain should be the term for the symptomatology arising from a particular pathomechanics that produces a periostitis of the medial tubercule of the calcaneal tuberos
One should cast the patient with the midtarsal joint fully pronated. If one casts with the forefoot inverted to the rearfoot, the orthotic will hold the foot in this position, maintaining the tension on the plantar fascia and the periosteum at its attachm
For an everted heel foot type, one should use a medial skive technique. For an everted forefoot type, one shoud use forefoot valgus extensions.
82
Author(s): 
By Paul R. Scherer, DPM, and Lori L. Waters, BSc, BEd

    Given the abundance of articles written about heel pain and plantar fasciitis, practitioners may wonder whether there is anything new to learn. The prevalence of this condition accounts for the amount of press that it gets, both in the medical community and in the news, but are all the articles and studies discussing the same thing? The numerous opinions and conflicting data may indicate that heel pain is more complicated than people realize. Perhaps some variable has been omitted in the research that contributes to the conflicting outcomes.

    Many terms are used interchangeably to describe heel pain. These terms include plantar fasciitis, plantar heel pain syndrome, heel bursitis, heel spur syndrome, subcalcaneal pain, chronic plantar heel pain and many others. Are all these terms truly discussing the same condition or are people using plantar fasciitis as a generic term for heel pain from different etiologies? Perhaps this is similar to how chondramalacia patellae became a catchall term for knee pain. Could this be why some patients respond well to your treatment regimen and others do not?

Establishing Clearer Terminology For Heel Pain

    Differentiating heel pain by its etiology is essential to successful treatment but this is not enough. We should establish clear definitions of the standard nomenclature in order to distinguish one type of heel pain from another. This can only help in future discussions, allowing practitioners and researchers to compare “apples to apples” and helping to reduce confusion regarding appropriate treatment choices for your patients. Even the names plantar fasciitis, plantar fascial strain, calcaneal bursitis and heel pain can cause confusion.

    In examining the etiology of heel pain, Lemont demonstrated that a histological examination of the most proximal aspect of the plantar fascia in patients who had plantar fasciotomies for symptoms showed no inflammatory cells.1 If there is no inflammation in the plantar fascia, should we call it plantar fasciitis? Shama reported a large prevalence of heel spurs and/or enthesopathies in patients who have no symptoms.2 If most patients with heel spurs do not have heel pain, why refer to heel pain as heel spur syndrome? Plantar heel pain is also called calcaneal bursitis. However, most anatomy texts do not show a bursa on the plantar aspect of the calcaneus.

    It should be apparent how these misnomers can cause confusion in discussions, research outcomes and treatment decisions.

Key Insights On Mechanically-Induced Subcalcaneal Pain

    To eliminate confusion when discussing heel pain, we suggest that the symptomatology that comes from a particular pathomechanics and produces a periostitis of the medial tubercle of the calcaneal tuberosity should be referred to as mechanically-induced subcalcaneal pain (MSC pain).

    MSC pain is defined by: 1) occurrence on the first step in the morning; 2) pain exacerbated by previous excessive activity; 3) improvement after walking; and 4) pain limited to the plantar area of the calcaneal tuberosity. Lastly, in order for heel pain to be MSC pain, the symptoms should not be related to other systemic seropositive/negative arthropathies or neuropathies, or to specific injury or trauma as determined by the patient history or examination.

    One aspect of our definition that we have not described is the particular pathomechanics that result in MSC pain. According to most articles, orthotic therapy can be successful in treating a significant portion of heel pain related to supination of the midtarsal joint and increased tension on the plantar fascia at its insertion. However, a brief summary of the suspected pathomechanics of MSC pain is in order to truly understand the parameters of treatment.

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