Breaking Out Of Our Apathy About Plantar Fasciopathy

Stephen Barrett DPM FACFAS

As I wrote in last month’s blog, I want to know more about human plantar fascia (see http://bit.ly/vDJesC ). I know you do as well because of the overwhelming response I had to the upcoming largest paper ever published on the subject of plantar fasciopathy. My goal is to have data on 1,000 plantar fascia, which come to the office cloaked in the simple costume of heel pain. I want to know what these fascia look like with high-resolution diagnostic ultrasound.

As I wrote last month — and as of this writing 621 people have read it — you can go to: http://www.surveygizmo.com/s3/700292/bd3b26d9e831 and print out the data sheet and instructions. Three days from now or, as in most practices, two hours from now, you will have the data and all you need to do is enter it. Just 200 of you taking a painless few minutes and we will have the largest heel pain study in the history of all universes, parallel and otherwise. I will sponsor a bottle of investment-grade “cult” red wine to a randomly selected data hero if we make 1,000 patients.

We have a little ways to go before I send out a bottle of cult investment grade cabernet. However, there is still opportunity for you to give me some data and maybe get a hold of some really special ambrosia.

Since this is the holiday season, I want to give each of you a few “Facts of Fasciopathy.” This knowledge may actually have some clinical application and get you out of that dangerous state of “FasciApathy.”

1) You can make a definitive diagnosis of plantar fasciopathy with sonography.1-5 If you are just using your thumb to palpate the medial calcaneal tubercle, spend some holiday money buying an ultrasound for your office. You need ultrasound more than a nice car, you can expense it off the taxes and it will return more than a United States savings bond.

2) There is a very high association of plantar fasciopathy with medial calcaneal nerve entrapment. It is for this reason that we have been talking about multiple etiology heel pain syndrome for nearly a decade.6,7

3) So how do you differentiate what is the most likely heel pain generator? This will give you some tremendous insight into how to attack the problem.

* What does the fascia look like on high-resolution diagnostic ultrasound? If it is normal, the fascia is less than 4 mm thick with normal signal intensity. Otherwise, the problem may be the nerve so don’t continue to treat patients for a problem with their plantar fascia.

* If the patient’s orthotic device increases the pain, think nerve. Don’t readjust the rearfoot posting or get the patient a new pair. Put the orthoses in the bag with the other seven pairs and tell the patient to store them in the closet for a while while you find your nerve.

* If you can elicit a provocation sign over the medial aspect of the heel (not the plantar aspect of the medial calcaneal tubercle), then drop 0.5 cc of lidocaine just subdermally in the region of the medial calcaneal nerve branch(es). Do so without blocking the medial or lateral plantar nerve, or tibial nerve and wait five minutes. (Please review Dellon’s article on the origin of the medial calcaneal nerve. It is great Christmas reading.8) You can do this while waiting for the nerve block to take effect. If patients have a significant reduction of pain, you have a new definitive diagnosis: entrapment of the medial calcaneal nerve. If they only have a partial improvement, then after reading Dellon’s article, give them another 0.5 cc according to his “map.” Now see how much pain they have.

What if they have both fasciopathy and nerve entrapment? Which do I treat first? Complex, isn’t it? How bad is the fasciopathy? Is it a grade IV C or a grade II B?5 This is why I want to collect some real data on this and I’m calling for your help. I can tell you from a fair amount of clinical experience that if it is a grade IV C, then treat the fasciopathy first and the patient’s medial calcaneal nerve entrapment will likely resolve spontaneously. If the fasciopathy is mild, you probably need to focus on the nerve (that is another blog in and of itself).

So now what about the results of our data collection? Out of the 621 readers, one took the time to input data on one patient. That, my friends, is a return rate of 0.00161031. If you ask a numerologist what 0.00161031 means, he will not hesitate to tell you the meaning: “Plantar FasciApathy.”

Come on! I know there are at least 10 more of those special individuals like our first respondent who can come to the plate with five cases each.

If you are suffering from “Plantar FasciApathy,” give yourself some ESWT or something. Happy holidays.

References

1. Kane D, Greaney T, Shanahan M, Duffy G, Bresnihan B, Gibney R, FitzGerald O. The role of ultrasonography in the diagnosis and management of idiopathic plantar fasciitis. Rheumatology (Oxford). 2001; 40(9):1002-1008.
2. Wall JR, Harkness MA, Crawford A. Ultrasound diagnosis of plantar fasciitis. Foot Ankle. 1993; 14(8):465-470.
3. Akfirat M, Sen C, Gunes T. Ultrasonographic appearance of the plantar fasciitis. Clin Imaging. 2003; 27(5):353-357.
4. Gibbon WW, Long G. Ultrasound of the plantar aponeurosis (fascia). Skeletal Radiol. 1999; 28(1):21-26.
5. Barrett SL. Endoscopic plantar fasciotomy--surgical technique. Techniques Foot Ankle Surg. 2011; 10(2):56-64.
6. Chang CW, Wang YC, Hou WH, Lee XX, Chang KF. Medial calcaneal neuropathy is associated with plantar fasciitis. Clin Neurophysiol. 2007; 118(1):119-123.
7. Rose JD, Malay DS, Sorrento DL. Neurosensory testing of the medial calcaneal and medial plantar nerves in patients with plantar heel pain. J Foot Ankle Surg. 2003; 42(4):173-177.
8. Dellon AL, Kim J, Spaulding CM. Variations in the origin of the medial calcaneal nerve. J Am Podiatr Med Assoc. 2002; 92(2):97-101.

Comments

Medial calcaneal nerve or Baxter's nerve (first branch of lateral plantar nerve)? Please clarify.
I thought that Baxter's nerve was more commonly involved.

Thank you.

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