Treatment of

Painful Heels

Due to Medial

Calcaneal Nerve

“Dock” DOCKERY, DPMdock.dockery@yahoo.com

Treatment of Painful Heels with 4% Alcohol Injection

Dock Dockery, DPM, FACFAS

Fellow, American College of Foot & Ankle Surgeons;

Fellow, American Society of Foot & Ankle Dermatology;

Fellow, American College of Foot & Ankle Pediatrics;

Fellow, American College of Foot & Ankle Orthopedics and Medicine;

Board Certified, American Board of Foot & Ankle Surgery;

Board Certified, American Board Podiatric Medicine;

Author of:

- Color Atlas & Text of Forefoot Surgery (Mosby 1992);

- Cutaneous Disorders of the Lower Extremity (WB Saunders 1997);

- Color Atlas of Foot & Ankle Dermatology (Lippincott 1999);

- Lower Extremity Soft Tissue & Cutaneous Plastic Surgery (Elsevier 2012)

Chairman and Director of Scientific Affairs, International Foot & Ankle Foundation;

Everett, Washington

dock.dockery@yahoo.com

Examination of Plantar Fascia –Medial Calcaneal Condyle

Direct Pressure to fascia

Insertion with Thumb

Direct Pressure to fascia

Insertion with Finger

Diagnosis of Heel Pain

Inferior Calcaneal Bursitis

Diagnosis of Heel Pain

Retrocalcaneal Bursitis/AICT

Diagnosis of Heel Pain

Inferior Calcaneal Periostitis/Fracture

Pulling-Distraction

causes increased

discomfort

Diagnosis of Heel PainPiezogenic Papules

Insertion of PF

Dockery GL, Diana JL: Painful piezogenic papules. JAPA,1978;680(10):703-705.

Diagnosis of Heel Pain

Piezogenic Papules

P.T. Nerve, Tendon

Area of MCN

Insertion of PF

Diagnosis of Heel PainTARSAL TUNNEL SYNDROME

A Cause of Heel Pain

Heel pain accompanied by neuropathic features such as

tingling, burning, or numbness may indicate tarsal tunnel

syndrome, a compression neuropathy caused by

entrapment of the posterior tibial nerve branches within

the tunnel.

Aldridge T. Diagnosis of Heel Pain in Adults. Am Fam Physician, 2004, 70(2):332-338.

Medial Calcaneal Nerve Pain

Diagnosis of Heel Pain

Insertional Plantar Fasciitis

Insertional Plantar Fasciitis

vs

Medial Calcaneal Neuropathy

Medial Calcaneal Nerve Pain

Medial Calcaneal Nerve Pain

Medial Calcaneal Nerve Pain

1st Branch of Lateral Plantar Nerve Pain (Baxter’s Neuritis)

• Baxter DE, Thigpen CM: Heel Pain – operative results. Foot Ankle 5:16-25, 1984.

• Baxter DE, Pfeffer GB. Treatment of chronic heel pain by surgical release of the

first branch of the lateral plantar nerve. Clin Orthop Relat Res. 1992; (279):229-36.

1st Branch of Lateral Plantar Nerve Pain (Baxter’s Neuritis)

• Baxter DE, Thigpen CM: Heel Pain – operative results. Foot Ankle 5:16-25, 1984.

• Baxter DE, Pfeffer GB. Treatment of chronic heel pain by surgical release of the first branch of the lateral

plantar nerve. Clin Orthop Relat Res. 1992; (279):229-236.

• Baxter DE. “Release of the Nerve to the Abductor Digiti Minimi” in Master Techniques in Orthopaedic Surgery

of The Foot and Ankle, p 359, Lippincott Williams and Wilkins, Phila, PA, 2002.

Abductor Digiti Minimi

Treatment of Heel Pain

Medial Calcaneal Nerve Pain

My “Preferred Treatment”

Dilute solution (4%) of ethyl alcohol

injected into medial calcaneal nerve region

of heel.

Done once per week (or every 10 days) until

symptoms resolve (up to seven injections)

4% Alcohol Injection Treatment of Painful Heels

4 % ALCOHOL SOLUTION:

48 cc of Local Anesthetic**(0.5% bupivacaine w/ epinephrine)

+ 2 cc of Dehydrated Alcohol

= 50 cc of 4% Sclerosing

4% Alcohol Injection Treatment of Painful Heels

48 cc of Local Anesthetic*

*(0.5% bupivacaine w/ epinephrine)

+ 2 cc of Dehydrated Alcohol

4% Alcohol Injection Treatment of Painful Heels

**IMPORTANT**

• Make a NEW label for the bottle

to prevent accidental injection

of the 4% Alcohol Sclerosing

Solution!

4% Alcohol Injection Treatment of Painful Heels

Add a NEW Label, 4% and Date

Mixture Made

4% Alcohol Injection Treatment of Painful Heels

1. “This alcohol solution has a very high affinity for nerve tissue and it produces neuritis and Wallerian nerve degeneration (chemical neurolysis)”

2. May cause a fine thin fibrous scar when injected at the deep dermal layers.

Dockery GL: Evaluation and Treatment of Metatarsalgia and Keratotic Lesions, in Myerson M

(ed): Foot and Ankle Disorders, W.B. Saunders. Phila., ch. 12, p.359-377, 2000.

4% Alcohol Injection Treatment of Painful Heels

INJECTION METHOD:• 0.5 cc (1/2 ml) of 4% Alcohol Solution

• 27 gauge, 5/8 inch needle

• Inject proximal to nerve pain

• Repeat Weekly (5 - 10 days)– injections Minimum: 3 Maximum: 7

ICD-9 Diagnostic Codes:Prior to 2016

• 355.8 neuritis, peripheral

• 355.9 nerve entrapment

• 997.61 amputation neuroma

• 956.4 nerve injury, skin/sensory

• 956.9 nerve injury, unspecified

• 729.5 pain, lower extremity

ICD-10 Diagnostic Codes:355.8--neuritis, peripheral

G57.6 Lesion of plantar nerve

G57.60 …… unspecified lower limb

G57.61 …… right lower limb

G57.62 …… left lower limb

G57.8 Other specified mononeuropathies of lower

limb

G57.80 Other specified mononeuropathies of

unspecified lower limb

G57.81 Other specified mononeuropathies of

right lower limb

G57.82 Other specified mononeuropathies of

left lower limb

355.9--nerve entrapment

Neuropathy, neuropathic

entrapment G58.9

977.61--amputation neuroma

Complication (s) (from) (of)

amputation stump (surgical) (late) T87.9

neuroma T87.30

956.4--nerve injury, skin/sensory

S94.3 Injury of cutaneous sensory nerve at ankle and

foot level

S94.30 Injury of cutaneous sensory nerve at ankle

and foot level, unspecified leg

S94.30XA …… initial encounter

S94.30XD …… subsequent encounter

S94.30XS …… sequelae

S94.31 Injury of cutaneous sensory nerve at ankle

and foot level, right leg

S94.31XA …… initial encounter

S94.31XD …… subsequent encounter

S94.31XS …… sequelae

S94.32 Injury of cutaneous sensory nerve at ankle

and foot level, left leg

S94.32XA …… initial encounter

S94.32XD …… subsequent encounter

S94.32XS …… sequelae

And….

ICD-10 Diagnostic Codes:956.9--nerve injury, unspecified

S94.8 Injury of other nerves at ankle and foot

level

S94.8X Injury of other nerves at ankle

and foot level

S94.8X1 Injury of other nerves at

ankle and foot level, right leg

S94.8X1A …… initial encounter

S94.8X1D …… subsequent

encounter

S94.8X1S …… sequelae

S94.8X2 Injury of other nerves at ankle and

foot level, left leg

S94.8X2A …… initial encounter

S94.8X2D …… subsequent

encounter

S94.8X2S …… sequelae

S94.8X9 Injury of other nerves at ankle and

foot level, unspecified leg

S94.8X9A …… initial encounter

S94.8X9D …… subsequent encounter

S94.8X9S …… sequelae

729.5--pain in lower extremity

M79.66 Pain in lower leg

M79.661 Pain in right lower leg

M79.662 Pain in left lower leg

M79.669 Pain in unspecified lower leg

M79.67 Pain in foot and toes

M79.671 Pain in right foot

M79.672 Pain in left foot

M79.673 Pain in unspecified foot

M79.674 Pain in right toe(s)

M79.675 Pain in left toe(s)

M79.676 Pain in unspecified toe(s)

MEDIAL CALCANEAL NERVE ENTRAPMENT

MEDIAL CALCANEAL NERVE ENTRAPMENT

Not All Heel Pain is Plantar Fasciitis or Insertional Fasciosis

Dockery GL: Dilute Alcohol Injections for Nerve Conditions and Keratotic

Lesions of the Foot. Podiatry Management. p.117-126, January 2004.

2018 CPT Codes

• 64455: Injection(s), anesthetic agent

and/or steroid, plantar common digital

nerve (e.g. Morton’s Neuroma)

• 64632: Destruction by Neurolytic Agent;

plantar common digital nerve or peripheral

nerve (i.e. alcohol)

• 64632 has a 10 day global and can be

used instead of 64640.

• Do not report 64632 and 64455 together

References

• Dockery GL: Treatment of Intermetatarsal Neuromas with 4% Alcohol Sclerosing Injections. JFAS, 38 (6): 403-408, 1999.

• Masala S, Fanucci E, Ronconi P, et al: Treatment of intermetatarsal neuromas with 30% alcohol injections under US guide. Radiol Med (Torino) 2001; 102:370-373.

• Fanucci E, Masala S, Fabiano S, et al: Treatment of intermetatarsal Morton’s neuroma with 10% alcohol injection under US guide: a 10-month follow-up. Eur Radiol. 2003 Mar;14(3):514-8.

• Hyer CF, Mehl LR, Block AJ, Vancourt RB: Treatment of Recalcitrant Intermetatarsal Neuromas with 4% Sclerosing Alcohol. JFAS, 44(4):287-291, 2005.[73% improved]

• Mozena J, Clifford J: Efficacy of Chemical Neurolysis for Treatment of Interdigital Nerve Compression of the Foot. JAPMA 97(3):203-206, 2007. [74% w/ 5 or more inj = 74% improved]

• Hughes RJ, Ali K, Jones H, Kendall S, Connell DA: Treatment of Morton’s Neuroma with Alcohol Injections Under Sonographic Guidance: Follow-up of 101 Cases. Am J. Roentgenology, 188:1535-1539, 2007.[84% pain free/94% improved]

Additional References• Alshami AM, Souvlis T and Coppieters MW: A review of plantar heel pain of neural origin: Differential

diagnosis and management, Manual Therapy, (13)2:103-111, 2008.

• Arenson DJ, Cosentino GL, Suran SM: The inferior calcaneal nerve. JAPA 70: 552, 1980.

• Baxter DE, Thigpen CM: Heel Pain-operative results. Foot Ankle 5:16, 1984.

• Baxter DE, Pfeffer GB: Treatment of chronic heel pain by surgical release of the first branch of the lateral

plantar nerve. Clin Orthop 279: 229, 1992.

• Baxter DE. “Release of the Nerve to the Abductor Digiti Minimi” in Master Techniques in Orthopaedic

Surgery of The Foot and Ankle, ed by HB Kitaoka, p 359, Lippincott Williams and Wilkins, Philadelphia,

2002.

• Dellon AL. Deciding when heel pain is of neural origin. J Foot Ankle Surg 40(5):341-5, 2001.

• Dellon AL, Kim J, Spaulding CM. Variations in the origin of the medial calcaneal nerve. J Am Podiatr

Med Assoc 92(2):97-101, 2002.

• Dockery GL: Dilute Alcohol Injections for Nerve Conditions and Keratotic Lesions of the Foot. Podiatry

Management. p.117-126, January 2004.

• Lareau CR, et al. Plantar and medial heel pain: diagnosis and management. JAAOS. 22(6):372-80,

2014.

• Panchbhavi VK. Plantar Heel Pain. Medscape Emedicine, Mar 2014.

http://emedicine.medscape.com/article/1233178-overview

• Rondhuis JJ, Huson A: The first branch of the lateral plantar nerve and heel pain. Acta Morphol Neerl

Scand 24: 269-279, 1986.

• Sammarco GJ, Helfrey RB: Surgical treatment of recalcitrant plantar fasciitis. Foot Ankle 17: 520, 1996.

• Sarrafian SK: "Nerves" in Anatomy Of The Foot And Ankle, p 381, JB Lippincott, Philadelphia, PA, 1993.

• Schon LC, Baxter DE. Heel pain syndrome and entrapment neuropathies about the foot and ankle. In:

Operative Foot Surgery. Gould JS (ed). WB Saunders, Philadelphia, pp 192-208, 1994.

• Young CC, et al. Treatment of plantar fasciitis. Am Fam Physician, 63(3):467-475, 2001.

Dock Dockery, DPM4% Alcohol Injections for Heel Pain

THANK YOU!

dock.dockery@yahoo.com