Heel pain

Mr Derek Park Consultant Orthopaedic Surgeon (Foot & Ankle)

NHS: Barnet & Chase Farm Hospital (Royal Free London NHS Foundation Trust)

Plantar heel pain• Background

• Illustrative case

• Differential diagnosis

• Treatment options

• Evidence

• Current management concepts

Mr DS• 51 yr old, commercial

manager, triathlon enthusiast

• 6m Hx plantar heel pain

• worse 1st thing in the morning, prolonged standing

• no radiculopathy, no neuropathy (DM/Alcohol)

• tried: insoles, night splints, calf stretches 3 months

Plantar heel pain

• Common condition

• Affects 1:10 adults

• Often self-limiting

• Recalcitrant cases can be challenging

AnatomyPF is closely connected to the paratenon of Achilles tendon, through the periosteum of the heel. Hence it is functionally & structurally continuous with TA

Anatomy• Type I collagen

• Supports medial longitudinal arch & aids propulsion, dissipates forces + stresses during gait and loading

• Visco-elastic property

• Ruffini & Pacinian corpuscles = mechanoreceptors

• Hyaluronan (HA) = proximally

Anatomy

Biomechanics

Biomechanics

Where is the pain

Differential diagnosis• Nerve

• sciatica; tarsal tunnel syndrome, FBLPN (N to ADQ)

• Soft tissue

• fibromatosis, bursitis, bruise, fat-pad atrophy

• Bone

• stress fracture, infection, tumour, Paget’s

History

• Plantar heel pain

• No trauma

• Pain on 1st steps

• Warms up

• Returns with prolonged WB

Examination

heel compression for stress fx Tinel’s test for tarsal tunnel or ADQ

Enthesopathy

• Associated with inflammatory arthropathy

• Heel spurs often found

• Medical management of inflammation

Mr DS• 51 yr old, commercial

manager, triathlon enthusiast

• 6m Hx plantar heel pain

• worse 1st thing in the morning, prolonged standing

• no radiculopathy, no neuropathy (DM/Alcohol)

• tried: insoles, night splints, calf stretches 3 months

Investigation

Night splint

Medial arch foot orthoses

1. Martin et al J Orthop Sports Phys Ther. 2014 2. Crawford & Thomson Cochrane review 2000, 2003

Treatment• Steroid injection

• risk fat atrophy

• risk of rupture

• Ultrasound guided

• Judicious use

• ESWT

Treatment• AOFAS position statement:

• Don’t perform surgery for PF before trying 6 months of nonoperative Rx (97% will resolve with 6 months of consistent, nonoperative Rx)

• Surgery is reserved as a last resort:

• Open or endoscopic plantar fascia release + release FBLPN +/- tarsal tunnel release

Mr DS

Evidence• Marginal gains only

• steroid injection - short term & small degree

• orthoses - prolonged standing

• limited evidence that stretching & heel pads are better than custom-made orthoses

• ESWT +ve but small effect1. Crawford & Thomson Cochrane 2000, 2003 2. Thomson & Crawford BMC 2005

Treatment

• GP - Physio - stretches - US - insoles - NSAIDS - taping - GP - MSK Triage - Acupuncture - Orthopaedic F&A surgeon

• Ortho F&A clinic - more physio - gastroc/PF stretches - imaging - review - desperate measures - pain clinic - CBT ….

Mr DS

Assessment• Ideal one-stop service: diagnosis, imaging,

treatment

• Determine gastrocnemius tightness: Silfverskiöld test

Gastrocnemius contracture• Restricted ankle dorsiflexion associated with

• chronic TA tendinopathy

• plantar heel pain

• acquired flat foot deformity

• midfoot OA

• metatarsalgia 1. Digiovanni et al 2002 JBJSAm

Treatment

TA stretching, technique important

Gastroc lengthening

Gastroc lengtheningClassic Strayer lengthening

PMGR

International meeting of the French Foot societies, Toulouse 2006

The role of gastrocnemius contracture

• Association between isolated gastrocnemius contracture and forefoot/hindfoot problems - DiGiovanni JBJS 2002, Patel & DiGiovanni FAI 2011

• Spectrum midfoot/arch collapse - J Anderson, D Bohay et al

Tibial nerve

Semimembranosus

Short saphenous vein

Midline

Medial Sural Cutaneous nerve

Common Peroneal

nerve

Lateral Sural Cutaneous

nerve

Anatomy

Hamilton et al. FAI 2009

Medial approach is free from nervous structures

Anatomy

Hamilton et al. FAI 2009

Medial head x-sectional area 2.4x Lateral

Technique

Technique

Fossa  is  medial

2.5  cm  incision  

Prone  Left  Leg

Technique

Surgeon’s  view

Prone  Right  Leg

Technique

Surgeon’s  view

Technique

Surgeon’s  view

Technique

Calf  Lengthening

PMGR  Level  4.5

PMGR

• Heel pain clinic

• Gastrocnemius contracture and its role in plantar fasciitis and Achilles tendinopathy

• Specific indications

• Stress ongoing management with eccentric stretching +/- ESWT

• Prospective consecutive series of 21 heels (17 patients) with recalcitrant plantar fasciitis

• Symptom duration 12 months to 6 years

• Positive Silfverskiöld’s test

• Confirmed with imaging (MRI, USS or bone scan)

• Average 24 months follow up (8-36 months)

• Outcome measure: 5 pt Likert scale, calf weakness, satisfaction

Results - PMGR in recalcitrant plantar fasciitis

Abbassian et al. FAI Jan 2012

5 point Likert scale

0

2

5

7

9

Worse No change Some improvementSignificant improvement Pain Free

88% recommend surgeryNo weakness1 minor wound complication

Abbassian et al. FAI Jan 2012

Mr DS

• Steroid injection

• ESWT

• Moderate improvement 30-40%

• Next steps…

Personal approach• Clinical assessment - include XRs,

USS to define pathology and PF thickness, r/o other pathology

• 6 months physio (lower limb team)

• If gastroc tight - stretch - PMGR

• If not - ESWT

• Consider steroid, PRP, ABT, HA, dry needling, acupuncture, topaz

• Defer surgery

Summary

• Aim for logical approach, step-wise management, and one-stop model

• Think of tight calves

• Consider non-operative measures always

• Evidence

References1. Hicks JH. The mechanics of the foot. II. The plantar aponeurosis and the arch. J Anat. 1954

Jan;88(1):25-30

2. Bolgla LA, Malone TR. Plantar fasciitis and the windlass mechanism: a biomechanical link to clinical practiceJ Athl Train. 2004 Jan;39(1):77-82

3. Shaw HM, Vázquez OT, McGonagle D, Bydder G, Santer RM, Benjamin M. Development of the human Achilles tendon enthesis organ. J Anat. 2008 Dec;213(6):718-24

4. Pavan PG, Stecco C, Darwish S, Natali AN, De Caro R. Investigation of the mechanical properties of the plantar aponeurosis. Surg Radiol Anat. 2011 Dec;33(10):905-11

5. Stecco C, Corradin M, Macchi V, Morra A, Porzionato A, Biz C, De Caro R. Plantar fascia anatomy and its relationship with Achilles tendon and paratenon. J Anat. 2013 Dec;223(6):665-76

6. Martin RL, Davenport TE, Reischl SF, McPoil TG, Matheson JW, Wukich DK, McDonough CM. Heel pain-plantar fasciitis: revision 2014. J Orthop Sports Phys Ther. 2014 Nov;44(11):A1-33