Heel pain |
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HEEL pain can either be on the back of the heel or under the heel. Pain at the back of the heel is usually due to Achilles tendinopathy and is outside the scope of this article. This section will focus on pain under the heel, which is due to plantar fasciitis.
Plantar fasciitis Aetiology Plantar fasciitis is the most common cause of heel pain and is commonly seen in females in their 50s. In athletes it is usually seen about ten years earlier. It is associated with obesity and in patients who spend the whole day on their feet, especially on hard surfaces. There is no evidence that overpronation causes the condition. However, it is commonly associated with tight Achilles tendons. 23
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History The common complaint is pain at the medial aspect of the heel, usually worse first thing in the morning. This is because foot plantar flexion is common when sleeping and the plantar fascia is particularly tight in the morning. Ask about tingling and numbness to exclude a less common nerve entrapment such as tarsal tunnel syndrome or Baxter’ s nerve entrapment. Ask about a history of inflammatory arthropathy and Dupuytren’ s disease. Inflamma- |
Figure 12. Calcaneal spur. Source: Lucien Monfils http:// bit. ly / 2xNzIal
tory arthropathy can exacerbate plantar fasciitis and Dupuytren’ s is associated with Ledderhose disease, which is fibromatosis of the plantar fascia. Ask about recent trauma or increase in activity as this can suggest a stress fracture of the calcaneus.
Examination Assess the patient for generalised obesity. Check the alignment of the hindfoot. Check ankle dorsiflexion as plantar fasciitis is usually exacerbated by Achilles and
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gastrocnemius tightness. Palpate the plantar fascia. Pain is usually pinpointed on the insertion at the medial heel and is exacerbated by dorsiflexion of the big toe. Generalised heel pain is not classical in plantar fasciitis and suggests heel pad atrophy or calcaneal stress fracture.
Investigations Imaging is only useful in cases where the diagnosis is doubtful. Blood tests may help if an inflammatory condition is suspected. An
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PAIN IS USUALLY PINPOINTED ON THE INSERTION AT THE MEDIAL HEEL AND IS EXACERBATED BY DORSIFLEXION OF THE BIG TOE.
ultrasound scan confirms diagnosis of a plantar fibromatosis and nerve conduction studies can exclude a nerve entrapment syndrome if this is suspected. Radiographs are only useful if a calcaneal stress fracture is suspected and an isotope bone scan may be a more useful investigation for this. Calcaneal spurs are frequently seen on plain X-ray, however, these are a normal finding and are not related to the underlying plantar fasciitis( see figure 12). The diagnosis of plantar fasciitis is usually clinical.
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Management The management of almost all plantar fasciitis is non-surgical and in Australia is best led by a sports physician. The main point to get across to the patient is that although plantar fasciitis will settle down with conservative measures, it can take 12-18 months. Initial management involves stretches. Studies have shown that plantar fascia stretches are more effective than Achilles stretches alone and the author prefers that the patient undertake both. 24 Dorsiflexion night splints are extremely effective in reducing morning pain. If these simple measures are not improving symptoms after a period of six months, the sports physician may offer a steroid injection or extracorporeal shock wave therapy. Evidence is limited for these procedures and is best guided by the sports physician. 25, 26 If the disease is recalcitrant to these measures, a specialist orthopaedic opinion may be sought for scarification of the plantar fascia and injection of either platelet-rich plasma or bone factors. If, after 12-18 months all conservative measures have been exhausted, surgical plantar fascial release is the final pathway. The author has used this procedure in rare cases refractive to non-operative measures. |
Case studies |
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Case study one: fix or fuse? ANNETTE, 72, has had bunions for many years. She is referred to the orthopaedic specialist for bunion correction because she is struggling with walking and the skin over her second toe is beginning to break down.
On examination, she has severe hallux valgus with obvious subluxation of the first metatarsophalangeal joints. The deformities are stiff and not correctable( see figure A) and she has multiple lesser toe deformities. She does not, however have much pain in the first metatarsophalangeal joint.
Radiographs reveal severe hallux valgus deformity with subluxation and arthritic changes in the first metatarsophalangeal joint and fixed deformities in the lesser toes( see figure B).
Annette is counselled on her options. As she had exhausted conservative measures and was unhappy with her feet, she wanted a correction of her deformities. Even a severe hallux valgus deformity can be corrected surgically. However the correction in a stiff joint requires significant shortening of the first ray and carries a risk of transfer metatarsalgia and progression of osteoarthritis. This would risk a second surgery and two prolonged periods of recovery for an older patient.
As such, after a discussion of the options we came to an agreement that bilateral first metatarsophalangeal joint fusions with deformity correction and correction of the lesser toes would be
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AB Case study 1. A: Attempted correction in coronal plane. B: Radiographs showing severe bunion with subluxation of MT head and loss of joint.
the best option for her. Plans were made for the rehabilitation and post-operative recovery and the procedure went ahead as planned.
An excellent correction was achieved and because of good preoperative planning, she spent one week in rehabilitation and then
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AN EXCELLENT CORRECTION WAS ACHIEVED AND BECAUSE OF GOOD PREOPERATIVE PLANNING, SHE SPENT ONE WEEK IN REHABILITATION THEN WENT HOME, WITH MODIFICATIONS TO HER ACCOMMODATION.
went home with modifications to her accommodation to assist her recovery.
At six months, Annette was back to her normal activities and very happy with the results of her surgery( see figure 8 radiograph of final correction).
Case study two: Can’ t you just chop out the neuroma? BARBARA, 55, is referred to the orthopaedic clinic with a burning pain between the third and fourth toes on her right foot.
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She had had symptomatic bunions for a number of years but had been coping with this with podiatric support. When the burning pain started, she was given a metatarsal dome which helped for some time but the pain had become progressively worse. She had two injections of steroids which helped for some months at a time but now she was fed up and wanted a lasting solution.
On examination, she has a moderate, correctable hallux valgus deformity( see figure A overleaf, showing that bunion is correctable). She has reduced sensation between the third and fourth toe and a positive Mulder’ s click.
Radiographs confirm moderate hallux valgus with an absence of osteoarthritis.
Barbara is counselled on her options. As she had tried all conservative options, surgery was deemed appropriate. Her options were either a simple neuroma excision, which would relieve her current symptoms but not deal with the underlying cause, or a forefoot reconstruction with hallux valgus correction.
She was counselled that although her current symptoms were due to the neuroma, this was likely caused by the hallux valgus deformity and as the second toe was beginning to cross over, this was likely to become more symptomatic.
Furthermore, hallux valgus correction in this scenario would not only halt progression of the hamcont’ d page 24
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