Conservative Heel Pain Treatment

Brian K. Bailey, DPM, MS

Podiatric Physician & Surgeon

Ashland, KY

(606) 324-FOOT (3668)

http://www.pandoracats.com/BMSPC/BMSPCmain.html

Plantar

Fasciitis

Plantar

Fasciitis

Plantar

Fasciitis

Inflammation and pain along the plantar fascia - the tissue band

that supports the arch on the

bottom of the foot

Usually on the bottom of the heel at the point where the plantar

fascia attaches to the heel bone

Becomes chronic in 5-10% of all

patients

Is not necessarily associated with

a heel spur

Over 90% resolve with conservative treatment

Plantar Fasciitis Symptoms

Pain on standing, especially after periods of

inactivity or sleep

Pain subsides, returns with activity

Pain related to footwear – can be worse in flat

shoes with no support

Radiating pain to the arch and/or toes

In later stages, pain may persist/progress

throughout the day

Pain varies in character: dull aching, “bruised”

feeling. Burning or tingling, numbness, or sharp

pain, may indicate local nerve irritation

Other Potential Causes of Heel Pain

Calcaneal apophysitis (children)

Arthritis GoutStress

fracture

Achilles tendon

problems Bone cyst

Pinched nerve/Nerve entrapment

Neuropathy

Low back or disk

problems

What is the diagnosis?

Posterior

Tibial

Tendon

Dysfunction

Also called “adult-acquired flat foot” and "progressive flatfoot," PTTD occurs when inflammation or damage to the posterior tibial tendon reduces its ability to support the arch. This often results in flattening of the foot, meaning the entire foot touches the floor when you’re standing. Although PTTD usually occurs in only one foot, some people may develop the condition in both feet. It typically will continue to get worse, particularly if it is not treated early.

Posterior Tibial Tendon Dysfunction

Symptoms

The symptoms of PTTD may include pain, swelling, a flattening of the arch, and an inward rolling of the ankle.

When PTTD initially develops, there is pain on the inside of the foot and ankle (along the course of the tendon). In addition, the area may be red, warm, and swollen.

As the arch begins to flatten, there may still be pain on the inside of the foot and ankle. But at this point, the foot and toes begin to turn outward, and the ankle rolls inward.

As PTTD becomes more advanced, the arch flattens even more and the pain often shifts to the outside of the foot, below the ankle. The tendon has deteriorated considerably, and arthritis often develops in the foot. In more severe cases, arthritis may also develop in the ankle.

Posterior

Tibial Tendon Dysfunction

Diagnostic

feature is the patient’s

inability or

difficulty in

performing a

unilateral heel

raise.

Weakness

inverting their foot

Posterior Tibial Tendon Dysfunction

Treatment

Mild PTTD is treated similarly to plantar fasciitis

Moderate to severe PTTD requires bracing

Start with a Swedobrace and schedule for casting for an AFO

Baxter’s nerve entrapment

Baxter’s

nerve

entrapment

The first branch of the lateral

plantar nerve becomes

entrapped in the medial heel

With entrapment, the pain is more

localized, it is pressure sensitive, and gets worse with activity rather

than better.

Usually responds well to ultrasound

guided corticosteroid injections

Injections only treat the symptoms,

so it is essential to treat the

causative underlying

biomechanical abnormalities

Tarsal

Tunnel

Syndrome

Tarsal Tunnel Syndrome

Entrapment of posterior tibial nerve

The most common cause is

repetitive pronation/supination

Pronation causes narrowing of the

tarsal tunnel

Positive Tinel’s and Valleix's sign

Tarsal Tunnel Syndrome

In a study published in Foot and Ankle International, Trepman et al. proved that eversion and inversion of the foot and ankle increased pressure in the tarsal tunnel, contributing to symptoms associated with entrapment of the posterior tibial nerve

By obtaining the MR I of 13 ankles in nine healthy subjects in three positions (neutral, eversion, and inversion), the authors observed that the mean tarsal tunnel volume was significantly greater when the foot and ankle were in the neutral position rather than in the full eversion or inversion.

The findings of this study imply that maintaining the foot and ankle in a neutral position can help in the treatment and management of tarsal tunnel syndrome by reducing pressure on the posterior tibial nerve and maximizing compartment volume of the tarsal tunnel.

Tarsal Tunnel Syndrome

Treatment of TTS and plantar fasciitis

are quite similar

What are some of the risk factors

these two causes of heel pain share?

Plantar Fasciitis Risk Factors

Biomechanical abnormalities

Overly tight calf muscle

Poor shoe choices

Weight gain

Barefoot walking

Work surface

Trauma

Plantar Fasciitis

Evaluation & Diagnosis

Pain with pressure on bottom of heel or arch

Limping

Foot Type: low vs. high arch, pronation

X-ray findings – Spur? Other abnormalities?

Ultrasound

Nerve Conduction Velocity studies to evaluate potential nerve problems

MRI –rarely used. Mostly for chronic, unresponsive cases

Plantar Fasciitis Treatment

Mechanical –

treat the cause

Anti-inflammatory –

treat the pain

Neither done in

isolation

Plantar

Fasciitis

Treatment

What I

learned in

training

Corticosteroid injections

Taping (Low Dye)

Running shoes

Orthotics

Dry Needling

Plantar fasciotomy

Plantar Fasciitis Treatment

Stretching, shoe modifications, avoid walking barefoot

Icing and rest

Night or resting splint

Supplemental arch support (OTC vs. custom orthotics)

Anti-inflammatory medication

Steroid injections

Physical therapy

If conservative measures fail, surgery is an option

Plantar Fasciitis TreatmentWhat I do now If there is any burning, tingling, numbness or sharp shooting

pain worse at night I order NCV, EMG.

If there is any HX of claudication, rest pain or diminished pulses

we schedule a PAD exam.

Bilateral digital x-rays to r/o stress fracture, tumor or other

osseous abnormalities. When I see heel spurs plantar or

retrocalcaneal I suspect a tight posterior muscle group.

Ultrasound exam and injection if the pain level warrants it and

the patient is okay with needles.

If no shot then diclofenac gel 4 grams topically to heel qid

Low Dye strapping and/or Swedo brace.

Measure for Saucony stability shoes

Plantar Fasciitis TreatmentWhat I do now Muscle strength testing including heel raise (PTTD)

Check for Tinel’s and Valleix's sign to R/O tarsal tunnel

Check for equinus if there is less than 10 degrees of

dorsiflexion an Equinus Brace is dispensed.

After two weeks in the Equinus Brace stability shoes are

dispensed

After two weeks in stability shoes and four weeks in EQ

brace OTC orthotics are dispensed

At this point 90% of patient have a pain level of 2/10 or less.

If pain is still significant a repeat injection or 4 weeks of

meloxicam

Other options for heel pain

Over 90% of heel pain patients respond to initial therapies within a relatively short period of time

For unresponsive cases, options include:

Minimally invasive procedures like ESWT (Extracorporeal Shock Wave Therapy)

Autologous Platelet Concentrate (APC) injection

Surgical procedures, open or endoscopic

Cryosurgery

Radiofrequency techniques

Low Dye StrappingCPT 29540

Low Dye

Strapping

CPT 29540

Low Dye StrappingCPT 29540

Amis – Frontiers in Surgery 2016 The Split Second Effect: The Mechanism of How Equinus Can Damage the Human Foot and Ankle

"We are awakening to a new era of understanding the mechanics

and function of the human foot and ankle. There is a simple,

singular, usually silent, and remote cause for the majority of non-

traumatic acquired foot and ankle pathology, and mechanically, it

creates cumulative damage to the foot and ankle through

leveraged forces. In short and in this author’s opinion, equinus is

the primary mechanical common denominator that leads to the

majority of acquired non-traumatic foot and ankle problems by

indirect leveraged means as well as direct forces along the

posterior/plantar chain. There can be no more room for the

standard thinking that these resultant foot and ankle problems

arise just because we are getting older or we are obese or they are

just random, or that an equinus contracture is only a part of the

equation. Equinus is the equation."

James Amis, MD

Silfverskiöld

Exam

examination

technique

position hindfoot

in supination

Dayton et al. JFAS 2017Experimental Comparison of the Clinical Measurement of Ankle Joint Dorsiflexion and Radiographic Tibiotalar Position

“Motion of the foot between the neutral and supinated positions introduced an

additional source of potential error from the measurement technique when using

the neutral position as the standard, which has been recommended in the past.

We recommend a supinated foot position as a more reliable foot position for

measuring the clinical ankle joint range of motion and propose it as a potential

standard.”

Liu & Xie HSSJ 2016 Association between Achilles tightness and lower extremity injury in children

page

033

Hill JAPMA 1995Ankle equinus. Prevalence and linkage to common foot pathology

page

034

“The podiatric

physician

should look

beyond the

specific

complaint to

diagnose the

underlying

cause.

Frequently,

ankle equinus

deformity will

be at the root of

the patient’s

foot problem.”

“Gastrocsoleus

stretching was

found to be an

effective

modality in

treating a wide

range of

podiatric

complaints

where ankle

equinus is an

underlying

etiologic factor.”

“Treating apparent biomechanical problems that have an underlying

equinus deformity with rigid functional orthoses is a major reason

for unsuccessful orthotic treatment.”

“Equinus patients who receive orthoses as their sole treatment may

not be capable of accepting orthotic control.”

“A rigid orthotic will prevent the foot from pronating. The result is

arch irritation from excess friction against orthoses.”

Hill JAPMA 1995

Ankle equinus. Prevalence and linkage to common foot pathology

Root et al “The worst foot in the world is the one

with the fully compensated equinus deformity.”

Johnson and Christensen “Equinus deformity is the

most profound causal agent in foot pathomechanics

and is frequently linked to common foot pathology.”

Hill “Equinus deformity is extremely prevalent, and

it appears to be a primary causal agent in a

significant proportion of foot pathology.”

EquinusYou are not paying enough attention!

page

036

“It has been postulated that epidemiologic factors, such as obesity,

sedentary life style, medical comorbities, shoe wear, concrete

floors, advanced age, female gender, and overuse issues, to

name a few, are responsible for a variety of foot and ankle

pathology. Although these factors might consistently coexist

with a variety of foot and ankle problems and seem to have a

causal relationship, it is my assertion that they have little if any

direct relationship.”

Amis Foot Ankle Clin N Am 2014

The Gastrocnemius: A New Paradigm for the Human

Foot and Ankle

“The singular and real association of each of these epidemiologic

factors is a contracture of the gastrocnemius muscle, which is

camouflaged in this list. Most every other cause of these foot and

ankle problems is likely mediated by contributing to the degree

and/or rate of an already contracting gastrocnemius. These

problems promote gastrocnemius tightness, which in time

causes incremental damage to the foot and/or ankle.”

Amis Foot Ankle Clin N Am 2014

The Gastrocnemius: A New Paradigm for the Human

Foot and Ankle

Conditions Associated with Equinus Documented in the Literature

• Heel Spur Syndrome/Plantar Fasciitis

• Achilles Tendinopathy

• Posterior Tibial Tendon Dysfunction

• Diabetic Foot Ulcers

• Charcot Neuropathy

• Metatarsalgia

• Morton’s Neuroma

• Lesser MPJ pathologies – PDS, Capsulitis

• Hallux Valgus

• Hammer Digit Syndrome

• Ankle Fracture/Sprains

• Sever’s Disease

• Pediatric Flatfoot Deformity

• Poor Balance/Fall Risk Elderly

• Low Back Pain

• Ankle Arthritis

• STJ Arthritis

• 1st Ray Hypermobility

• Adult Pes Plano Valgus

• Hallux Limitus

• Sesamoiditis

• Lateral Column Syndrome/Foot Pain

• Freiberg’s Infarction

• Forefoot Callus

• Iliotibial Band Syndrome

• Medial Tibial Stress Syndrome/Shin Splints

• Patellofemoral Syndrome

• Chronic Ankle Instability

• Tibial Stress Fractures

• Osteoarthritis Forefoot/Midfoot

• Muscle Strains

• Genu Recurvatum

• Arch Pain

• Anterior Compartment Syndrome

• Forefoot Nerve Entrapment

“In clinical practice, the early destructive influence of

equinus is often not appreciated. Instead, we are

usually faced with the end result of equinus effects…”

Johnson & Christensen – JAFAS 2005

Biomechanics of the First Ray Part V: The Effect of

Equinus Deformity

“The authors strongly recommend careful clinical

assessment and appropriate treatment of equinus in

patients with biomechanical deformities affecting the

first ray and midfoot.”

Johnson & Christensen – JAFAS 2005

Biomechanics of the First Ray Part V: The Effect of

Equinus Deformity

Cheung et al. Clinical Biomechanics 2006 Effect of Achilles tendon loading on plantar fascia tension in the standing foot

page

042

Amis Frontiers in Surgery 2016 The Split Second Effect: The Mechanism of How Equinus Can Damage the Human Foot and Ankle

Split Second Effect – Ankle Joint Dorsiflexion

1. Starts the last ½ of midstance when swing phase foot starts to pass the stance foot

2. Ends as stance heel lifts just prior to 3rd Rocker beginning

3. Lasts approximately 120ms (1/10th second)

4. Leveraged & direct forces act upon foot & ankle or “start up” gait (limping) develops

5. “Start up” limp gait ⇒ Rest & lack of calf tension ⇒ Worsen calf tightness (Law of Davis)

6. 1000’s steps/per day over period of years ⇒ “occult, unrecognized, overuse of imbalance” ⇒ damage

to foot & ankle

Consensus Statement: The panel reached consensus that the statement “Stretching is safe

and effective in the treatment of plantar fasciitis” was appropriate.”

“Tight hamstrings and equinus are common in patients with plantar fasciitis. Treatment of

equinus is important for all stages of plantar fasciitis.”

“The consensus of the panel is that stretching is extremely important in the treatment of

plantar fasciitis. The type of stretching protocol (home stretching, night splint, or physical

therapy) will vary according to the severity of the equinus and patient preference. No

consensus was reached regarding the type of stretching needed. However, the panel agreed

that more aggressive stretching would be preferred.”

Schneider et al – JFAS 2018ACFAS Clinical Consensus Statement

American College of Foot and Ankle Surgeons Clinical Consensus Statement: Diagnosis and Treatment of Adult Acquired

Infracalcaneal Heel Pain

Why manual stretching fails

• Compliance – not stretching long enough

daily (>30 minutes/day)

• Lack of follow though – minimum of 6

weeks

• Improper stretching technique – heel off

ground, knee bent or not in full extension,

STJ not in supination

page

046

Manual stretching mistakes

page

047

Manual stretching mistakes

page

048

Why night splints fail

page

049

Why night splints fail

ideal equinus bracing concepts

page

050

lock knee into

full extension

01

above the knee

Controllable ankle

joint dorsiflexion –

prevent over

stretching and allow

for precision of

treatment

02

controllable

hinges

Engage Windlass

mechanism to supinate the

STJ creating DF primarily

in the hindfoot and not in

the midfoot, external

rotation of the tibia

allowing for full knee

extension via the “screw

home mechanism”

03

stretch in

supination

page

051

The Equinus Brace™

DeHeer’s RecommendationsConservative Equinus Management

page

052

02Stretch both legs at the

same time if both have

equinus deformity

0

3

Check monthly until

above +5°, then

employ a

maintenance therapy

program

0

1

1 hour/day seated

upright to also

stretch

hamstrings

Brian K. Bailey, DPM, MS

Podiatric Physician & Surgeon

Ashland, KY

(606) 324-FOOT (3668)

http://www.pandoracats.com/BMSP

C/BMSPCmain.html

Thank you for coming today!