insider’s guide fdm approach to chronic plantar heel … · plantar fasciitis is the most common...

Functional Medicine Training Program Page1 of 37 Insider’s Guide – FDM Approach to Plantar Heel Pain

Copyright © 2008 Sequoia Education Systems, Inc

Functional Medicine University’s Functional Diagnostic Medicine

Training Program

INSIDER’S GUIDE

FDM APPROACH TO CHRONIC PLANTAR HEEL PAIN

By Ron Grisanti, D.C. & Dicken Weatherby, N.D. http://www.FunctionalMedicineUniversity.com

Limits of Liability & Disclaimer of Warranty We have designed this book to provide information in regard to the subject matter covered. It is made available with the understanding that the authors are not liable for the misconception or misuse of information provided. The purpose of this book is to educate. It is not meant to be a comprehensive source for the topic covered, and is not intended as a substitute for medical diagnosis or treatment, or intended as a substitute for medical counseling. Information contained in this book should not be construed as a claim or representation that any treatment, process or interpretation mentioned constitutes a cure, palliative, or ameliorative. The information covered is intended to supplement the practitioner’s knowledge of their patient. It should be considered as adjunctive support to other diagnostic medical procedures.

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Table of Contents

CHRONIC PLANTAR HEEL PAIN ....................................................................................................... 3 THE PLANTAR FASCIA .......................................................................................................................... 3 BASIC ANATOMY AND FUNCTION ........................................................................................................... 5

Biomechanical Aspect of Plantar Fasciitis ..................................................................................... 6 PRESENTING SYMPTOMS ...................................................................................................................... 6 PATHOPHYSIOLOGY ............................................................................................................................. 6 MORTALITY/MORBIDITY ........................................................................................................................ 7 RISK FACTORS .................................................................................................................................... 7 HISTORY ........................................................................................................................................... 10 EXAMINATION .................................................................................................................................... 11 BIOMECHANICAL MOTION PALPATION .................................................................................................. 12

Anteroposterior glide of the distal intermetatarsal joints .............................................................. 12 Rotation Mobility .......................................................................................................................... 13 The Tarsometatarsal Joints ......................................................................................................... 13 Tarsometatarsal Rotation ............................................................................................................. 14

DIFFERENTIAL DIAGNOSES ................................................................................................................. 15 CAUSES OF PLANTAR HEEL PAIN ........................................................................................................ 16

Nerve Entrapment Syndromes ..................................................................................................... 16 Tarsal Tunnel Syndrome .............................................................................................................. 18 Entrapment of the Lateral Plantar Nerve ...................................................................................... 18

ENTRAPMENT OF THE MPN ................................................................................................................ 18 HEEL PAD DISORDERS ....................................................................................................................... 18 INFECTIOUS ETIOLOGIES .................................................................................................................... 19

Neuroma of LPN, MCN and MPN ................................................................................................ 19 Plantar Fascial Rupture ............................................................................................................... 19 Calcaneal Stress Fracture ........................................................................................................... 20 Calcaneal Apophysitis.................................................................................................................. 20 Systemic Disorders ...................................................................................................................... 20

THE MYOFASCIAL CONNECTION AND PLANTAR FASCIITIS ...................................................................... 21 LABORATORY STUDIES ....................................................................................................................... 24 IMAGING STUDIES .............................................................................................................................. 25 BIOMECHANICAL MEASUREMENTS FOR PES PLANAS ............................................................................. 25

CYMA line .................................................................................................................................... 25 AP-Talar-1st metatarsal angle ..................................................................................................... 27

LATERAL TALOCALCANEAL ANGLE ....................................................................................................... 28 HOME THERAPY ................................................................................................................................. 31

Golf Ball and Rolling Pin Technique ............................................................................................ 31 PERPETUATION OF THE MYOFASCIAL CONNECTION ................................................................................ 32 REFERENCES: ................................................................................................................................... 33



Chronic Plantar Heel Pain

One of the most common foot disorders encountered by health professionals is chronic plantar heel pain (CPHP). It has been reported to account for 15% of all adult foot complaints requiring professional care.

A variety of soft tissue, osseous, and systemic disorders can cause heel pain. Narrowing the differential diagnosis begins with a history and physical examination of the lower extremity to pinpoint the anatomic origin of the heel pain.

Several well-known conditions may lead to plantar heel pain such as plantar fasciitis, calcaneal fracture, rupture of the plantar fascia and atrophy of the heel fat pad. Plantar heel pain may also have a neural origin, with a lesion or dysfunction of the tibial, plantar or calcaneal nerves. Nerve entrapment and myofascial trigger points may also play a role in both acute and chronic conditions of plantar heel pain. It is also important to make note that there are some systemic diseases which are known to cause chronic plantar heel pain and again need to be ruled out.

Today’s lesson will focus primarily on the most common plantar heel pain and that is plantar fasciitis, however, we will discuss other associated causes that need to be investigated before an effective treatment is started.

In the literature CPHP has been described as painful heel syndrome, plantar fasciitis, subcalcaneal bursitis, neuritis, medial arch pain, subcalcaneal pain, stone bruise, calcaneal periostitis, subcalcaneal spur

The Plantar Fascia The plantar fascia is a thick band of fibrous tissue that arises from the medial and lateral calcaneal tubercles and runs to the plantar metatarsal heads, where it connects with the transverse metatarsal ligament.The plantar fascia provides extensive support to both the longitudinal arch and the trans-verse metatarsal arch.



The typical complaint shared by most individuals is pain under the medial heel during weight-bearing that is worse when standing after periods of rest or on taking the first steps in the morning. The nature of the pain has been described as burning, aching and occasionally lancinating.

Plantar fasciitis is the most common cause of plantar heel pain and the term has been used generically to describe heel pain at the origin of the plantar fascia on the medial calcaneal tuberosity. Chronic plantar fasciitis is predominantly characterized by a marked collagen degeneration of the plantar fascia and inflammation.

Plantar fasciitis may have several different clinical presentations. Although pain may occur along the entire course of the plantar fascia, it is usually limited to the inferior medial aspect of the calcaneus, at the medial process of the calcaneal tubercle. This bony prominence serves as the point of origin of the anatomic central band of the plantar fascia and the abductor hallucis, flexor digitorum brevis and abductor digiti minimi muscles.

As with many conditions where the true etiology is unclear, CPHP has become a generalized term encompassing a broad spectrum of pathologies affecting the heel. However, plantar fasciitis is considered to be the most common cause of pain and the terms are used interchangeably in the literature.



Basic Anatomy and Function

Muscle Origin Insertion Action Nerve abductor hallucis

medial tubercle of calcaneum

medial side, base proximal phalanx

big toe

flexes, abducts big toe. Supports medial

longitudinal arch

medial plantar

flexor digitorum

brevis

medial tubercle of calcaneum

middle phalanx of four lateral toes

flexes lateral four toes. Supports medial and

lateral longitudinal arches

medial plantar

abductor digiti minimi

medial and lateral tubercles of calcaneum

lateral side base proximal phalanx

fifth toe

flexes, abducts fifth toe. Supports lateral

longitudinal arch

lateral plantar nerve

accessory flexor

(quadratus plantae)

medial and lateral sides of calcaneum

tendon flexor digitorum longus

aids long flexor tendon to flex lateral four toes

first lumbrical-medial plantar; remainder-deep

branch lateral plantar

lumbricals tendons of flexor digitorum longus

dorsal extensor expansion of

lateral four toes

extends toes at interphalangeal joints

medial plantar

flexor hallucis brevis

cuboid, lateral cuneiform; tibialis posterior insertion

medial and lateral sides of base of proximal phalanx

of big toe

flexes metatarsophalangeal

joint of big toe; supports medial longitudinal arch

medial plantar

adductor hallucis,

oblique head

bases second, third, fourth metatarsal

bones

lateral side base proximal phalanx

big toe

adducts big toe, supports transverse

arch

deep branch lateral plantar

adductor hallucis,

transverse head

capsules 3, 4, 5 metatarsophalangeal

joints

lateral side of base of proximal phalanx, big toe

adduct big toe deep branch lateral plantar

flexor digiti minimi brevis

base of fifth metatarsal

lateral side base of proximal

phalanx small toe

flexes little toe lateral plantar

dorsal interossei

adjacent sides of metatarsals

bases of phalanges and

dorsal expansion of corresponding

toes

abduct toes, using second toe as

reference flex

metatarsophalangeal joints; extend

interphalangeal joints

lateral plantar

plantar interossei

3rd, 4th, 5th metatarsals

bases phalanges and dorsal

expansion 3rd, 4th, 5th toes

adduct toes using second toe as

reference flex

metatarsophalangeal joints; extend

interphalangeal joints

lateral plantar



Biomechanical Aspect of Plantar Fasciitis

Most cases of plantar fasciitis are the result of a biomechanical fault that causes abnormal pronation. For example, a patient with a flexible rearfoot varus may at first appear to have a normal foot structure but, on weight-bearing, may display significant pronation. The talus will plantar flex and adduct as the patient stands, while the calcaneus everts. This pronation significantly increases tension on the plantar fascia.

Other conditions, such as tibia vara, ankle equinus, rearfoot varus, forefoot varus, compensated forefoot valgus and limb length inequality, can cause an abnormal pronatory force. Increased pronation with a collapse produces additional stress on the anatomic central band of the plantar fascia and may ultimately lead to plantar fasciitis.

This is understandable since the weakest point of the plantar fascia is its origin, not its substance (because of the high tensile strength of the fascial fibers themselves

Presenting Symptoms Patients usually describe pain in the heel on taking the first several steps in the morning, with the symptoms lessening as walking continues. The pain often is described as a searing or tearing of the tissues under the heel and often improves with further activity, only to recur following continued or prolonged weightbearing activity.

They frequently relate that the pain is localized to an area that the examiner identifies as the medial calcaneal tubercle. The pain is usually insidious, with no history of acute trauma. Many patients state that they believe the condition to be the result of a stone bruise or a recent increase in daily activity.

Pathophysiology The origin of the plantar fascia on the calcaneus is an area that has fibrocartilage at the site of attachment to bone. This specialized zone of tissue has longitudinal fibers of collagen to resist tension but is metabolically active in the formation of cartilage. Therefore, the healing response may lead to calcified cartilage and eventual bone formation. There is a rich pattern of sensory innervation within the plantar fascia that includes the tissue near the attachment to the calcaneus. This may explain why repair processes beneath the heel are so painful. Plantar fascia pain may be due to long-term damage with incomplete repair leading to an endless cycle of reparative attempts by the local tissue. The chemical mediators of inflammation most likely are the proximate cause of pain, thus the pain-relieving effects of anti-inflammatory medication reported in clinical experience. The actual repair of torn collagen fibers may be impaired by the mechanical demands of the plantar fascia with repetitive high loading in both tension and compression.



Another process affecting the fascia from within is myxoid degeneration and replacement of normal matrix with abnormal substances that are mechanically inefficient. Spontaneous rupture of all or part of the fascia may occur in extremely high-load situations, and the natural healing of torn fascia often is complicated by painful scar formation.

Mortality/Morbidity Morbidity associated with plantar fasciitis primarily is the pain of weightbearing activity. Patients who rupture the fascia acquire a characteristic foot deformity that is similar to pes planus: collapse of the longitudinal arch, valgus of the calcaneus, and abduction of the forefoot. The collapsed foot may require custom insole orthotics and accommodative shoes or corrective surgery to realign and fuse the hindfoot. Mortality data from this condition are not available, though of itself, plantar fasciitis is not a lethal condition. The notable exception is the rare soft-tissue sarcoma in the foot, as when fibrosarcoma of the plantar fascia is the pathological condition. An estimated 30 such sarcomas of the foot are reported annually in the United States. Due to the delay in diagnosis of most soft-tissue sarcomas of the foot, the 5-year survival rate is less than 10%.

Risk Factors Many risk factors for the development of the condition have been hypothesized in the literature and are commonly classified as intrinsic or extrinsic. Intrinsic risk factors are anatomical and biological characteristics of individuals that predispose them to CPHP. Biological factors suggested in the literature include increasing age, increasing body mass index (BMI), height and weight gain; anatomical factors include limited ankle dorsiflexion, leg length discrepancy, heel pad thickness, increased plantar fascia thickness, pes planus (excessive pronation of the foot), cavus (high arched) foot, muscle imbalance, limited first metatarsophalangeal joint (MPJ) range of motion (ROM) and calcaneal spur. Postulated extrinsic factors include prolonged weight bearing, improper shoe fit and wear, previous injury and running variables such as surface, speed, frequency and distance per week. Foot biomechanics are implicate such as the cavus foot with the rigid high medial arch and limited heel pronation imparts increased stress within the substance of the plantar fascia. Also at risk is the flexible pes planus with abduction of the forefoot and pronation of the hindfoot causing large tensile strain in the plantar fascia. The achilles tendon and triceps surae, when contracted, are a source of excessive stress with the plantar fascia.



• Increased body mass index Increased body mass index is strongly associated with chronic plantar heel pain in a nonathletic population. Higher prevalence with body-mass index (BMI) >30

• Ankle ROM

Evidence suggests that there may be an association between reduced ankle dorsiflexion and CPHP.

• Foot posture (Decreased calcaneal pitch)

Calcaneal pitch is defined as the angle formed by drawing a line along the inferior border of the calcaneus and a line drawn in the horizontal plane. A lower calcaneal pitch indicates a greater degree of pronation.

The lower the calcaneal pitch the greater the risk of developing CPHP.

• The relationship of pes planus and calcaneal spur to plantar heel pain • Prichasuk S. Subhadrabandhu T. Department of Orthopaedics and Rehabilitation Medicine, Faculty of Clinical

Orthopaedics & Related Research. (306):192-6, 1994 Sep. A prospective study of pes planus by using calcaneal pitch and calcaneal spur was carried out in 82 patients with plantar heel pain and in 400 normal subjects. The mean normal calcaneal pitch was 20.54 degrees. The mean calcaneal pitch in patients with plantar heel pain was 15.99 degrees, which was significantly lower than in normal subjects. The incidence of calcaneal spur in normal subjects and in patients with plantar heel pain was 15.5% percent (62 of 400) and 65.9% (54 of 82), respectively. Again, this was a highly significant difference. Excessive weight gain, aging, and gender may be important factors effecting the lowering of the pitch and the increasing of spur formation. These factors could lead to the development of plantar heel pain.



• First MPJ extension

• Prolonged standing

History The history should provide a description of the pain and related conditions and circumstances. The location and onset of heel pain, its variation in character and severity throughout the day, and the relieving and aggravating factors all provide important diagnostic clues. Increased levels of activity or exercise may indicate a musculoskeletal injury caused by overuse. If the patient describes the sensation as "burning," "tingling," or "numbness," the cause may be peripheral nerve entrapment.

Systemic disorders are uncommon causes of heel pain; however, a history of diabetes, rheumatologic disorders, or malignancy should prompt consideration of a systemic cause for heel pain, especially when there is no obvious local etiology. Be observant of the following during the history taking

• Pain on plantar surface of calcaneus • Worst when arising out of bed; after prolonged sitting • Described as “pebble in shoe” • Pain with prolonged ambulation or standing • Limp with excessive toe walking



• Numbness and burning medial hindfoot with posterior tibial nerve compression Another characteristic of plantar fasciitis is the location of the pain, which usually is at the origin of the plantar fascia from the medial portion of the posterior calcaneus. The following specific questions should be asked about the patient's pain:

• Where is the pain? • Is it always in the same place? • Is it worse with the first few steps in the morning? • Does it go away with rest?

Examination The physical examination should include inspection of the patient's foot at rest and in a weight-bearing position. A visual survey of the foot may reveal swelling, bony deformities, bruising, or skin breaks. The physician should palpate bony prominences and tendinous insertions near the heel and midfoot, noting any tenderness or palpable defects. Passive range of motion of the foot and ankle joints should be assessed for indications of restricted movement. Foot posture and arch formation should be visually examined while the patient is bearing weight; the physician is looking for abnormal pronation or other biomechanical irregularities.

Observation of the foot while the patient is walking may allow the physician to identify gait abnormalities that provide further diagnostic clues. Pay close attention to possible point tenderness on calcaneus at insertion of plantar fascia as well as pain along plantar fascia with foot dorsiflexion.



Biomechanical Motion Palpation

Anteroposterior glide of the distal intermetatarsal joints

The joint-play movement of anteroposterior glide of the head of the fifth metatarsal bone on the head of the fourth.



Rotation Mobility

The joint-play movement of rotation of the head of the fifth metatarsal bone upon the head of the fourth

The Tarsometatarsal Joints

Be observant of the fact that there are synovial joints facets between the bases of the metatarsal bones. Joint-play movements at the tarsometatarsal joints and proximal intermetatarsal joints are: Anteroposterior glide

With the patient supine, position yourself perpendicular to the foot to be tested. Grasp over the top of the patient's forefoot with your active caudad hand and over the patient's tarsals with your cephalad hand (stabilizer). The curve of the patient's foot should fit comfortably within the webs of both hands. With the bases of the patient's meta-tarsals firmly stabilized, push downward and then lift upward with your active hand to produce A –P and P-A motion between the metacarpal bases and the articulating tarsals. If motion resistance is perceived, impulse against the fixation.



Anteroposterior glide at the joints between the bases of the meta-tarsal bones and the distal row of the tarsal bones.

Tarsometatarsal Rotation

Sit facing the patient's foot, and rotate the patient's forefoot as a whole into eversion and then inversion so that the bases of the metatarsals will rotate on the articulating tarsals. This maneuver will also elicit intermetatarsal restrictions. If fixation is found, it can usually be released with the classic figure-8 maneuver.

Movement of rotation of the bases of the metatarsal bones on the distal row of tarsal bones

The Midtarsal Joints Anteroposterior Glide

The technique to evaluate midtarsal glide is the same as that described above for tarso-metatarsal glide except that the hands are moved cephalad so that the evaluating force can



be directed at the midtarsal articulations.

Anteroposterior glide at the midtarsal joint

Differential Diagnoses • Posterior tibial nerve compression • Painful or atrophic heel pad • Tendonitis of posterior tibialis • Calcaneal stress fracture • Pain from neoplasm or infection • Spondyloarthropathy • Rheumatoid arthritis • Polymyositis • Tendonitis of peroneus brevis • Tendonitis of peroneus longus • Tendonitis of the flexor digitorum longus • Tendonitis of the flexor hallucis longus • Achilles tendonitis • Retroachilles bursitis • Retrocalcaneal bursitis



• Pain in the plantar aspect of heel • Plantar fasciitis • Plantar fascia rupture • Tarsal tunnel syndrome • Neuroma • Bone cyst • Osteomyelitis

Causes of Plantar Heel Pain

Less common causes of heel pain should be considered before a treatment regimen for plantar fasciitis is undertaken. These include sciatica, tarsal tunnel syndrome, entrapment of the lateral plantar nerve, rupture of the plantar fascia, calcaneal stress fracture and calcaneal apophysitis (Sever's disease).

Nerve Entrapment Syndromes

Nerve entrapment has also been considered an important cause of plantar heel pain. In particular, the first branch of the LPN and the MCN are implicated in this condition. The diagnosis of plantar heel pain with a neural origin is dependent on a careful history and physical examination.

In patients with plantar heel pain of neural origin, pain is usually characterized as burning, sharp, shooting, shock-like, electric, localized or radiating either proximally or distally, and occasionally as dull aching. Typically, pain is worse during or after weight-bearing activities and improves with rest. However, pain may also occur with rest and in non-weight bearing positions. Pain at night may be due to nerve compression as a result of venostasis (slowing of venous outflow) and venous engorgement (local congestion and distension with blood).

The tibial nerve is the larger of the two major divisions of the sciatic nerve, and distally it divides into the following branches: medial calcaneal nerve (MCN), medial plantar nerve (MPN), lateral plantar nerve (LPN) and the first branch of the LPN.



While contribution of the MCN to plantar heel pain of neural origin is well documented most authors have implicated the first branch of the LPN in this condition Patients with entrapment of the first branch of the LPN represent 15–20% of the patients with chronic plantar heel pain.

Compression of the tibial nerve at the tarsal tunnel, a condition called tarsal tunnel syndrome (TTS), can also contribute to plantar heel pain.

Entrapment of the MPN occurs where the fascial sling can bind the nerve beneath the talus and navicular bone.

Entrapment of the LPN can result from compression between the abductor hallucis and quadratus plantae muscles.

The first branch of the LPN, also called the nerve to abductor digiti minimi innervates the flexor digitorum brevis, quadratus plantae and abductor digiti minimi muscles. Although it gives off sensory branches to the calcaneal periosteum this nerve does not supply the skin.



The majority of studies included in this review reported that entrapment of the first branch of the LPN is the most common cause of plantar heel pain of neural origin.

Tarsal Tunnel Syndrome

Entrapment of the Lateral Plantar Nerve

Entrapment of the first branch of the lateral plantar nerve has been said to cause plantar medial heel pain. The entrapment usually occurs between the abductor hallucis muscle and the quadratus plantae muscle, giving patients a burning sensation on the plantar aspect of the heel that is aggravated by daily activities and may even persist at rest. Palpation of this area may prove painful, with a tingling sensation. Palpation over the abductor hallucis and/or on the medial calcaneal tuberosity may reproduce symptoms in all patients with suspected neurological plantar heel pain.

The diagnosis of entrapment of the first branch of the LPN should not be made without the presence of maximal tenderness over the nerve, although the entire heel and the proximal plantar fascia may also be tender.

Entrapment of the MPN

MCN is the second most commonly reported nerve that has been related to plantar heel pain of neural origin.

The MPN innervates the abductor hallucis, flexor hallucis brevis, flexor digitorum brevis and first lumbrical, and the skin of the medial two-thirds of the plantar aspect of the foot.

Diagnosis of entrapment of the anterior branch of the MCN can be substantiated by the following palpatory findings:

1. maximal tenderness over the medial anterior part of the heel fat pad and abductor hallucis 2. distally radiating pain with pressure on the nerve 3. only minimal tenderness over the plantar fascia origin.

With MPN entrapment, tenderness is typically located over the plantar aspect of the medial arch around the navicular tuberosity

Heel Pad Disorders

The heel pad is composed of columns of adipose tissue separated by fibrous septa. It is located directly beneath the calcaneus and acts as a hydraulic shock-absorbing layer.

In patients with a soft and thin heel fat pad, pain is usually aggravated by hard-soled shoes and walking on hard surfaces.



Although the symptoms of heel pad disorders overlap considerably with those of plantar fasciitis, heel pad pain is typically more diffuse. Heel pad pain involves most of the weight-bearing portion of the calcaneus, whereas plantar fasciitis pain is centered for the most part near the calcaneal tuberosity. In contrast to pain caused by plantar fasciitis, heel pad pain tends not to radiate anteriorly, and dorsiflexion of the toes does not increase the pain. Pain is most intense over the central portion of the heel fat pad The pain does not radiate, and the medial calcaneal tuberosity and plantar fascia are not tender.

Infectious Etiologies

Although rarely a cause of heel pain, osteomyelitis of the calcaneus generally results from contiguous infection of surrounding soft tissue. During a visual examination of the foot, clues that should increase suspicion of a possible infectious cause for heel pain include puncture wounds, open skin lesions, localized warmth, erythema, or apparent cellulitis. Serious foot infections are more likely to occur in patients who have diabetes mellitus or vascular insufficiency. Radionuclide bone scanning and MRI are more sensitive and specific than plain-film radiographs in diagnosing osteomyelitis.

Neuroma of LPN, MCN and MPN 14-35

Although uncommon, heel pain caused by a neuroma of the LPN, MCN and MPN may present with symptoms quite similar to those of plantar fasciitis. Palpation of the sole over the heel and proximal midfoot may pinpoint a painful lump (known as the "lamp cord" sign because the lump feels like a lamp cord under a rug) that easily can be misdiagnosed as inflamed plantar fascia. If conservative treatment of plantar fasciitis fails to alleviate symptoms, the physician should evaluate for a neuroma. Patients with neuroma may complain of occasional local paraesthesia and loss of sensation and a Tinel's test may also be positive.

Plantar Fascial Rupture

Rupture of the plantar fascia is an uncommon cause of plantar heel pain. Patients often report severe pain in the medial arch following physical trauma. Some patients have been misdiagnosed and treated unsuccessfully for several months with steroid injections for presumed plantar fasciitis. Magnetic resonance imaging can aid greatly in the diagnosis of this condition.

Physical examination may reveal a palpable deficit in the plantar fascia or a small enlarged area at the distal aspect of the plantar fascial rupture. Patients also experience severe pain on palpation of the plantar fascia, with maximal tenderness generally distal to the medial process of the calcaneal tuberosity. Gait analysis usually reveals a significant limp that spares the affected limb. Treatment consists of immobilization with a nonweight-bearing short-leg cast or a removable boot cast and a regimen of NSAID therapy. Immobilization for four to six weeks is usually required before ambulation without pain is possible.



Calcaneal Stress Fracture

Acute heel pain caused by calcaneal stress fractures can closely resemble the symptoms usually associated with plantar fasciitis. The history may reveal a recent abrupt increase in daily exercise or other activities. Patients with this condition often report increased pain on direct medial to lateral compression of the calcaneus. This type of elicited pain is rarely present in patients with plantar fasciitis.

Calcaneal Apophysitis

Calcaneal apophysitis (Sever's disease) usually affects boys between six and 10 years of age, chiefly those who are obese and those who are extremely active. In most cases, the pain is located in the posterior aspect of the calcaneus and is more severe after athletic activity.

Palpation of the posterior aspect of the calcaneus around the insertion of the Achilles tendon usually reveals local tenderness. Patients with this disorder may have a tight Achilles tendon with limited ankle dorsiflexion, which sometimes causes patients to walk on their toes to decrease the pain.

Systemic Disorders

Heel pain may occur in patients with various systemic inflammatory conditions, including rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, Reiter's syndrome, gout, Behçet's syndrome and systemic lupus erythematosus.

Gonorrhea and tuberculosis have also been implicated as causes of heel pain, but such an association is rare.

Most patients with systemic disease present with joint pain and inflammation in other areas of the body, but symptoms may occasionally begin in the heel.

A detailed history and physical examination may disclose the symptom complexes of an arthritic disease. For example, a young man who reports bilateral heel pain and who has a history of conjunctivitis or urethritis for more than one month may have Reiter's disease.

Similarly, heel pain in a patient with a history of psoriasis and asymmetric pain in the distal interphalangeal joints of the fingers and toes should raise the possibility of psoriatic arthritis.

When heel pain is of systemic origin, treatment should, of course, be directed at the primary disease state. Radiographs of patients with systemic inflammatory conditions may show posterior or plantar exostoses, but these findings are not clinically important.



Although the number of patients whose heel pain is caused by systemic arthritic diseases is small in comparison to those with pain from other causes, these arthritic diseases still must be ruled out through appropriate physical examination and laboratory studies before the heel pain is treated.

Patients with known systemic arthritis conditions, bilateral heel pain, or symptoms involving joints beyond the heel should undergo a thorough review of symptoms to assess for systemic illness as a possible cause of heel pain. The seronegative spondyloarthropathies (i.e., ankylosing spondylitis, psoriatic arthritis, reactive arthritis, and inflammatory bowel disease-associated arthritis) may produce heel pain. Bilateral plantar heel pain is reported in less than 30% of cases, and bilateral involvement is associated with systemic disorders of an inflammatory nature. Furthermore, plantar heel pain may be the initial or prodrome of a systemic disorder in as many as 15% of cases, with inflammatory arthritis being the most likely disorder to develop.

The Myofascial Connection and Plantar Fasciitis

Plantar fasciitis is generally attributed to repeated traction with micro-tears of the plantar aponeurosis, which produce an inflammatory degeneration of the plantar aponeurosis at its site of attachment on the medial tubercle of the calcaneus.

Tension overload is caused by a tight Achilles tendon that increases tension on the aponeurosis,

excessive walking, running, or jumping, and pes planus with pronation of the foot on weight bearing. Medical studies point out that tightness of the plantar aponeurosis may result from tension of the muscles that anchor to it. These are intrinsic muscles that function as flexors of the toes: the abductor hallucis, flexor digitorum brevis, and abductor digiti minimi. Myofascial trigger



points cause chronic shortening of muscles that harbor them.

The fact that many of the symptoms and signs of plantar fasciitis are also characteristic of several myofascial pain syndromes raises the question as to whether trigger points may be contributing significantly to the chronic overload of the plantar aponeurosis in many of these patients. The muscles most likely to be involved are the intrinsic flexors of the toes, the gastrocnemius, and the soleus. The area of heel pain and tenderness of plantar fasciitis matches partly the referred patterns of the soleus, quadratus plantae, and abductor hallucis muscles.



The distribution of pain and tenderness along the plantar fascia fits the pattern produced by trigger points in the flexor digitorum longus muscle.



The intrinsic flexors of the toes can be overloaded by a sudden increase in running and jumping activities. The pain produced on passive extension of the great toe in plantar fasciitis is also characteristic of trigger points in the abductor hallucis muscle.

Laboratory Studies Routine blood or urine evaluation has no proven value in patients with suspected plantar fasciitis, however, serology for inflammatory conditions such as rheumatoid arthritis or ankylosing spondylitis,



infection and other systemic diseases may be helpful confirmatory studies if those diagnoses are considered. The possibility of infection and/or inflammatory disorders may be supported by an elevated white blood cell count, erythrocyte sedimentation rate, and C-reactive protein, RA factor, etc.

Imaging Studies Plain radiographs should be part of the work-up for patients with foot problems. The reason for obtaining a radiograph of the foot is to look for causes other than plantar fasciitis that would account for heel pain and for comparison with future radiographs. The lateral radiographic view may reveal an osteophyte, soft-tissue calcification, or stress fracture of the calcaneus, or it may reveal a foreign body or arthrosis of the subtalar joints. Ultrasound imaging, magnetic resonance imaging (MRI), and nuclear bone scan all have value in identifying abnormality in the area of concern. If symptoms have been unresponsive to treatment for more than 3 months, MRI of the hindfoot and electrical diagnostic nerve tests are indicated to detect processes such as plantar fascia rupture, muscle inflammation, compression neuropathy, and stress changes in the calcaneus. The application of advanced imaging studies is helpful when the clinical diagnosis is not clearly supportive of plantar fasciitis or when multiple diagnoses are considered.

Biomechanical Measurements for Pes Planus

CYMA line

A cyma line is an architectural term designating the union of two curve lines. A normal midtarsal joint should create a smooth cyma between the talonavicular joint and calcaneocuboid joint on both the AP and lateral views. If the cyma line is broken it suggests "shortening" of the calcaneus relative to the talus. This is often just a radiographic shortening possibly due to rotation of the talus on calcaneus (typically seen in a patient with adult flatfoot including loss of the medial arch).



Line between talonavicular joint and calcaneocuboid joint on the above left is smooth and continuous and the line on the above right is broken Lateral View

The line connecting talonavicular joint and calcaneocuboid joint is smooth and continuous



This represent a broken Cyma line of pes planus

AP-Talar-1st metatarsal angle

This is another method for evaluating the degree of midfoot and forefoot abduction. A line drawn through the mid-axis of the talus should be in line with the first metatarsal shaf. If it is angled medial to the first metatarsal it indicates pes planus.

The view on the left shows a normal talar-1st metatarsal angle on AP view with a line drawn trough the mid-axis of the talus passes through the base of the first metatarsal and angled



laterally in relation to the long axis of the shaft of the metatarsal. The right view above shows an abnormal talar-1st metatarsal angle, angled medial to the first metatarsal.

Lateral Talocalcaneal Angle

The lateral talocalcaneal angle is the angle formed by the intersection of the line bisecting the talus with the line along the axis of the calcaneus on lateral weight-bearing views. A line is drawn at the plantar border of the calcaneus (or a line can be drawn bisecting the long axis of the calcaneus).The other line is drawn through two midpoints in the talus, one at the body and one at the neck. The angle is formed by the intersection of these axes. The normal range is 25-45 degrees. An angle over 45 degrees indicates hindfoot valgus, a component of pes planus.



Conservative treatment It is imperative that you do a great history and examination and be certain you identify the specific nature of the patient’s plantar heel pain before you proceed with treatment. Mechanical treatment for a systemic disease causing plantar heel pain will ultimately fail. Once you have ruled out non-mechanical causes of chronic plantar heel pain, the following are considered the common treatments that have proven to be effective.

• Rest • Myofascial release (trigger point therapy: abductor hallucis, flexor digitorum brevis, abductor

digiti minimi, gastrocnemius, soleus, quadratus plantae, and flexor digitorum longus muscle) • Mobilization of hypomobile joints of foot • Taping 26-22



• Non-steroidal anti-inflammatory drugs • Extracorporeal shock wave therapy • Visco-elastic heel pads and heel cups • Night dorsiflexion splints maintain the foot at an angle of 90 degrees or more to the ankle

and prevent contraction of the plantar fascia while the patient sleeps. • Laser • Medial longitudinal arch supports • Foot orthoses: Orthotic devices are the mainstay of ongoing conservative treatment for

patients with plantar fasciitis. The biomechanical factors that cause the abnormal pronatory forces stressing the medial band of the plantar fascia must be corrected. Patients with pes cavus feet may benefit from using a flexible orthotic device with an additional heel cushion.

• Ultrasound • Soft-soled shoes • Stretching exercises for the achilles tendon and plantar fascia • Casting • Surgery



Home therapy

Conservative treatment of plantar fasciitis should address the inflammatory component that causes the discomfort and the biomechanical factors that produce the disorder. Patient education is imperative. Patients must understand the etiology of their pain, including the biomechanical factors that caused their symptoms. They should learn about home therapy that may relieve some discomfort and about recommended changes in daily activities, such as wearing appropriate athletic shoes with a significant medial arch while walking. Patients whose symptoms are associated with a recent increase in exercise should adopt a less strenuous regimen until the plantar fasciitis resolves.

Each night for 10 to 14 days, the patient should apply an ice pack to the plantar aspect of the heel 15 to 20 minutes before going to bed. An alternative approach is to massage the plantar fascia with an ice block (made up of water frozen in a paper cup) for 15 minutes per day for two weeks.

Golf Ball and Rolling Pin Technique



When using the Golf-ball Technique, the patient places enough body weight on the golf ball to find the tender spots in the muscles. Then the patient can either apply steady ischemic compression or roll the ball over the tender spot along the tight band to perform a modification of stripping massage. This technique is especially useful for applying effective pressure to the flexor digitorum brevis and to that part of the abductor digiti minimi that lies deep to the plantar aponeurosis. The Rolling-pin Technique is less specific technique but still effective. With the foot flat applie pressure to the flexor digitorum brevis, flexor hallucis brevis, and the abductor hallucis. The patient can effectively work the muscles along the sides of the foot by inverting the foot to work the abductor digiti minimi and everting the foot to work the abductor hallucis. For key is to slowly roll the pin throughout the length of the tender part of the muscle.

Perpetuation of the myofascial connection A hard slippery surface under a desk chair with wheels can overload the toe flexors that must repeatedly help pull the chair close to the desk. Walking or running on uneven terrain and on surfaces that slope transversely can perpetuate trigger points in the intrinsic muscles of the feet.



References:

insider’s guide fdm approach to chronic plantar heel … · plantar fasciitis is the most common...

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