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Plantar Heel Pain

QU LIUXIN

SOUTHEAST UNIVERSITY ZHONGDA HOSPITAL

Introduction
Plantar heel pain is a commonly encountered orthopedic problem that can cause significant discomfort and a limp because of the difficulty in bearing weight. The etiologies of this condition are multiple; therefore, a careful clinical evaluation is necessary for its appropriate management. Nonsurgical or conservative care is successful in most cases.

Pathophysiology
The heel pain can also have a neurologic basis. The tibial nerve, with nerve roots from L4-5 and S2-4, courses in the medial aspect of the hindfoot, through the tarsal tunnel, under the flexor retinaculum, and over the medial surface of the calcaneus. The calcaneal branch, arising directly from the tibial nerve, carries sensation from the medial and plantar heel dermis. The tibial nerve divides into lateral and medial plantar nerves, which proceed into the plantar aspect of the foot through a foramen within the origin of the abductor hallucis muscles, which forms the distal tarsal tunnel. The first branch of the lateral plantar nerve changes course from a vertical to a horizontal direction around the medial plantar heel. It passes deep to the abductor hallucis muscle fascia and the plantar fascia and is the nerve supply to the abductor digiti minimi muscle. The tibial nerve and its branches in the hindfoot can be involved with compressive neuropathies. A valgus heel can stretch in the tibial nerve.

Frequency
United States More than 2 million Americans seek treatment for plantar heel pain each year. International In both athletic and nonathletic populations, the incidence of plantar fasciitis is reported to be approximately 10%. Age The average age of a patient with proximal plantar fasciitis is approximately 45 years.

Clinical history
A careful history and physical examination is valuable in identifying the etiology of heel pain. Taking a comprehensive medical and general history is important in order to distinguish between various causes. Seek the history on all the characteristics of the pain, such as onset, location, radiation, modifying factors, relation to time of the day, and relation to activities.

The most common cause of plantar heel pain in both athletic and nonathletic populations is proximal plantar fasciitis. Patients usually have occupations that involve spending most of their time on their feet. The pain is often unilateral, but it can manifest bilaterally, with one side being more painful than the other. The discomfort commonly manifests spontaneously and insidiously without an antecedent trauma or fever. Occasionally, some patients state they might have stepped on a small object such as a pebble or they may have recently started an exercise regimen involving walking or running. Some patients may have a history of recent weight gain.

The pain is localized to the plantar and medial aspects of the heel. It is worse typically with the first few steps in the morning. The pain causes patients to limp for approximately half an hour. It is also worse after a period of rest, such as after standing up from a chair or getting out of a car. The pain then improves with walking and stretching, but prolonged walking and standing aggravate the pain. The pain can be present with every step, causing a limp, and patients tend to walk bearing weight on the forefoot and the outer aspect of the foot.

An acute onset of pain, especially after a vigorous or sudden athletic activity, can be indicative of traumatic rupture of the plantar fascia. Fat pad atrophy in elderly patients and in persons who have received multiple steroid injections manifests with pain under the heel that is more diffuse, involving most of the weight-bearing surface. The pain worsens when the patients walk on hard surfaces and when they wear hardsoled footwear. The initial improvement in walking observed in patients with plantar fasciitis is not observed in patients with fat pad atrophy.

Pain radiating from the heel distally or proximally and associated with numbness, paresthesia, or a burning sensation after activity and continuing even after rest is likely to be neurologic in origin. This is usually due to a compressive neuropathy locally, as in tarsal tunnel syndrome, or proximally at the level of the nerve root, in which case low back pain may be associated. Bilateral heel pain and pain at the tendon insertions (or enthesopathy), especially associated with general symptoms such as malaise, recurrent fever, multiple joint pains, or bowel dysfunction, may indicate an association with inflammatory disorders such as rheumatoid arthritis, spondyloarthropathies, Reiter syndrome, or Behcet syndrome.

Physical
A general examination is necessary to rule out systemic causes of heel pain. A spine examination is required if the pain radiates.

In the local examination, inspect the foot and the heel for any abnormalities such as swelling, lumps, scars, bruising, or foot deformities such as pes planus or pes cavus. Palpation is performed to elicit the site of maximum tenderness. Check the condition of the fad pad, feel for defects or lumps in the plantar fascia, and identify any bony deformity due to previous fractures. Palpation should be done on or around lumbarsacral spine. Percussion over the tibial nerve in the tarsal tunnel and its distal branches is performed to check for hypersensitivity or tingling. Percussion over any previous scars in the region can be performed to detect a neuroma in the scar.

imaging
Plain weight-bearing radiographs can show calcaneal spurs in approximately 50% of patients with plantar fasciitis, but, because spurs are frequently noted in patients without heel pain, the presence of calcaneal spurs is not considered contributory to the pain, and it does not affect the diagnosis or treatment. Plain radiographs can show lumbar and sacral abnormal such as bony spur, disc narrowing, sacroiliac joint changed, intervertebral joints dislocation, especialy in L5 and S1.

Causes
Local Proximal plantar fasciitis Fat pad atrophy Plantar fascia rupture Tarsal tunnel syndrome Compression of the first branch of the lateral plantar nerve Plantar fasciitis coexisting with compression of the first branch of lateral plantar nerve Stress fracture of the calcaneus Bone tumor or bone cyst Osteomyelitis

Regional Spinal stenosis Prolapsed intervertebral disc Systemic Inflammatory bowel disease associated arthritis Seronegative spondyloarthropathies Inflammatory arthritis (ie, rheumatoid arthritis)

Treatment
Proximal plantar fasciitis is successfully managed with conservative care in approximately 90% of cases. In general, the longer the duration of symptoms, the longer it takes for the patient to obtain complete pain relief. Various modalities of treatment are available, and patient education is important to improve the understanding of the condition and to obtain compliance with various treatment regimens. The important aims of the treatment are to limit impact stresses on the heel, to alleviate inflammation, and to stretch the triceps surae muscle.

Orthopaedic manipulation in L5 and S1, sometimes in sacroiliac joint. Corticosteroid injection.

Stretching and strengthening


Exercises: A variety of exercises can help the patient to achieve active and passive ankle dorsiflexion with the knee kept straight and the subtalar joint in inversion, which helps achieve maximum stretch of the triceps surae muscle. The foot can be rolled over a tennis ball or a can to massage and stretch the plantar fascia. The exercises can be performed at home or can be guided by a physical therapist.

Plantar fasciaspecific stretching exercises: A randomized, prospective study with 2-year follow up compared Achilles tendon stretching with plantar fascia tissuespecific exercises.16 The authors found a plantar fasciaspecific stretching exercises was better. To perform the exercise, the patient crosses the affected leg over the contralateral leg. While placing the fingers across the base of the toes, the patient pulls the toes back toward the shin until he or she feels a stretch in the arch or plantar fascia. The patient confirms that the stretch was correct by palpating tension in the plantar fascia.

Thank you for your attention !

SOUTHEAST UNIVERSITY ZHONGDA HOSPITAL


Name: QU LIUXIN Address: Dingjiaqiao 87, Nanjing, China Tel: 0086 13813085677 E-mail: quliuxin@yahoo.com.cn Blog: http://i.cn.yahoo.com/quliuxin/blog/ Skype: qlx5677

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