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Heel pain and plantar fasciitis
- 1. BY: Dr. DANIEL JOSEPH AUGUSTINE MOSC MEDICAL COLLEGE, KOLENCHERY
- 2. INTRODUCTION Unique structure Sustain large weight bearing stresses The arches supported by muscles, ligaments, aponeurosis, shape of bones help in various functions
- 4. CALCANEUM
- 6. COMMONEST CAUSES OF HEEL PAIN Plantar Fasciitis Retrocalcaneal Bursitis Calcanel spur Fat Pad Atrophy Epiphysitis Of Calcaneum Pump Bump Plantar Fibromatosis
- 7. PLANTAR FASCIA The plantar fascia is the thick connective tissue which supports the arch on the bottom of the foot It runs from the tuberosity of the calcaneus forward to the heads of the metatarsal bones It is composed of three segments:
- 9. PLANTAR FASCIITIS Plantar fasciitis is a painful foot condition caused by inflammation of insertion of the plantar fascia on the medial process of the calcaneal tuberosity.
- 10. ETIOLOGY • Obesity, Flat Foot, Prolonged standing • Decreased ankle dorsiflexion • Congenital- Pes cavus/ Pes planus • Reiters disease, Ankylosing spondylitis • Weight bearing activity (dancing, running) • Fat pad atrophy • Tight calf muscles
- 11. PATHOPHYSIOLOGY Chronic overuse leads to microtears in the origin of the plantar fascia Repetitive trauma leads to recurrent inflammation and periostitis
- 12. C/F Sharp heel pain: Insidious onset , often when first getting out of bed, may prefer to walk on toes Worse at the end of the day after prolonged standing, relieved by ambulation Common B/L Tender to palpation at medial tuberosity of calcaneus Dorsiflexion of the toes and foot increases may increase tenderness with palpation
- 14. INVESTIGATIONS Radiographs often normal, r/o calcaneal stress # may show plantar heel spur weight bearing axial/lat films of hindfoot may show structural changes MRI - thickening of plantar fascia Bone Scan - increased uptake can quantify inflammation useful to rule out stress fracture
- 16. TREATMENT NON OPERATIVE Pain control, Splinting & Stretching Plantar fascia and Achilles tendon stretching Anti-inflammatories /cortisone injections Taping Foot Orthosis Cushioned heel pads, pre-fabricated shoe inserts, night splints, walking casts Short leg casts can be used for 8-10 weeks
- 18. TAPING Calcaneal taping or low-dye taping used for short-term pain relief. Taping does cause improvement in function.
- 19. OPERATIVE: Perisistent pain after 9 months of failed conservative measures. 1. Surgical release with plantar fasciotomy: done open or arthroscopically 2. Surgical release with plantar fasciotomy and distal tarsal tunnel decompression
- 20. RETROCALCANEAL BURSITIS Inflammation of the bursa between the anterior aspect of the Achilles and posterior aspect of the calcaneus Common in young patients
- 21. C/F Pain localized to anterior and 2 to 3 cm proximal to the Achilles tendon insertion Fullness and tenderness medial and lateral to tendon Pain with dorsiflexion Bony prominence at Achilles insertion
- 22. INVESTIGATIONS Radiograph: (L) foot demonstrates Haglund deformity
- 23. TREATMENT NON OPERATIVE Activity modification, Shoe wear modification, NSAIDs Shoewear with external padding of Achilles tendon OPERATIVE Retrocalcaneal bursa excision and resection of Haglund deformity- in refractory cases
- 24. CALCANEAL SPUR It is a spike of bone at the anterior edge of calcaneal tuberosity (usually medial or posterior) ETIOLOGY Repeated attacks of plantar fasciitis Repeated trauma Ill fitting footwear Plantar Fibromatosis
- 25. C/F Pain over ball of heel Tenderness on plantar aspect of heel Swelling at attachment of plantar fascia INVESTIGATIONS Radiography (L) Shows bony spike arising from calcaneum
- 27. TREATMENT CONSERVATIVE Rest, NSAIDs, hydrocortisone injection, MCR footwear SURGICAL Osteotomy of calcaneum Excision of medial calcaneal tuberosity
- 28. FAT PAD ATROPHY Common in athletes or follows a direct blow to the area. Separation of the fat pad from the bone, loss of its normal shock-absorbing effect and atrophy Palliative Treatment Wearing soft-soled shoes or shock-absorbing heel cups Foot baths Anti-inflammatory agents.
- 29. EPIPHYSITIS OF CALCANEUM Traction ‘apophysitis’/Sever’s disease Common in boys~10 years. It is a mild traction injury. Pain and tenderness-localized to the tendo Achillis insertion. Radiography: increased density and fragmentation of the apophysis. TREATMENT The heel of the shoe should be raised
- 31. PUMP BUMP Inflammation of superficial bursa situated over insertion of tendoachilles Caused d/t rubbing of the back part of pump shoes, common in women Not true tendonitis
- 32. PLANTAR FIBROMATOSIS Proliferative fibroplasia of the plantar aponeurosis. Nodules can be felt on medial non weight bearing side of aponeurosis TREATMENT Conservative: modification of shoe Wide surgical excision
Editor's Notes
- The foot is really unique to human being. The structure of the foot allows the foot to sustain large weight bearing stresses under a variety of surfaces and activities that maximize stability and mobility. Arches of the foot help in fast walking, running, jumping, weight bearing and in providing upright posture. Arches are supported by intrinsic and extrinsic muscles of the sole in addition to ligaments, aponeurosis and shape of the bones.
- There are three groups of bones in the foot : the seven tarsal bones, which form the skeletal framework for the ankle; metatarsals (I to V), which are the bones of the metatarsus; the phalanges, which are the bones of the toes-each toe has three phalanges, except for the great toe, which has two the heel is the prominence at the posterior end of the foot. It is based on the projection of one bone, thecalcaneus or heel bone
- Calcaneus Body_ID: HC006195 The calcaneus sits under and supports the talus.The calcaneus projects behind the ankle joint to form the skeletal framework of the heel. The posterior surface of this heel region is circular and divided into upper, middle, and lower parts. The calcaneal tendon (Achilles' tendon) attaches to the middle part: the upper part is separated from the calcaneal tendon by a bursa; the lower part curves forward, is covered by subcutaneous tissue, is the weight-bearing region of the heel, and is continuous onto the plantar surface of the bone as the calcaneal tuberosity. The calcaneal tuberosity projects forward on the plantar surface as a large medial process and a small lateral process separated from each other by a V-shaped notch. At the anterior end of the plantar surface is a tubercle (the calcaneal tubercle) for the posterior attachment of the short plantar ligament of the sole of the foot.
- Ligament and muscle support Ligaments and muscles support the arches of the foot: ligaments that support the arches include the plantar calcaneonavicular, plantar calcaneocuboid, and long plantar ligaments, and the plantar aponeurosis; muscles that provide dynamic support for the arches during walking include the tibialis anterior and posterior, and the fibularis longus Plantar aponeurosis : The plantar aponeurosis is a thickening of deep fascia in the sole of the foot (Fig. 6.109). It is firmly anchored to the medial process of the calcaneal tuberosity and extends forward as a thick band of longitudinally arranged connective tissue fibers. The fibers diverge as they pass anteriorly and form digital bands, which enter the toes and connect with bones, ligaments, and dermis of the skin. Distal to the metacarpophalangeal joints, the digital bands of the plantar aponeurosis are interconnected by transverse fibers, which form superficial transverse metatarsal ligaments. Body_ID: P006686 The plantar aponeurosis supports the longitudinal arch of the foot and protects deeper structures in the sole. long plantar ligament is the longest ligament in the sole of the foot and lies inferior to the plantar calcaneocuboid ligament (Fig. 6.102B): posteriorly, it attaches to the inferior surface of the calcaneus between the tuberosity and the calcaneal tubercle plantar calcaneocuboid ligament is short, wide, and very strong, and connects the anterior calcaneal tubercle to the inferior surface of the cuboid (Fig. 6.102A). It not only supports the calcaneocuboid joint, but also assists the long plantar ligament in resisting depression of the lateral arch of the foot
- Longitudinal arch Body_ID: HC006219 The longitudinal arch of the foot is formed between the posterior end of the calcaneus and the heads of the metatarsals (Fig. 6.107A). It is highest on the medial side where it forms the medial part of the longitudinal arch and lowest on the lateral side where it forms the lateral part. Body_ID: P006680 Transverse arch Body_ID: HC006220 The transverse arch of the foot is highest in a coronal plane that cuts through the head of the talus and disappears near the heads of the metatarsals where these bones are held together by the deep transverse metatarsal ligaments Arches of foot Purposes: 1. Help support weight-bearing 2. Absorb shock of weightbearing 3. Provide space on bottom of foot for blood vessels, nerves. Anterior Metatarsal Arch • Transverse Arch • Medial Longitudinal Arch • Lateral Longitudinal Arch
- demographics affects men and women equally location affects the posteromedial heel risk factors obesity (high BMI) decreased ankle dorsiflexion in a non-athletic population (tightness of the foot and calf musculature) Excessive pronation of the foot. Poor arch support in the shoe Flat foot Prolonged standing Fat pad atrophy Tight triceps surae Repetitive strength imbalances Over use may cause microtears and inflammation Congenital problems such as Pescavus and Pesplanus Obesity Reiters disease,Ankylosing spondylitis,Diffuse idiopathic skeletal hyperostosis weight bearing endurance activity (dancing, running)
- Tight calf muscles: Having tight calf muscles can cause excessive foot pronation contributing to excessive foot mobility which increases the level of stresses on the plantar fascia. demographics affects men and women equally location affects the posteromedial heel risk factors obesity (high BMI) decreased ankle dorsiflexion in a non-athletic population (tightness of the foot and calf musculature) Excessive pronation of the foot. Poor arch support in the shoe Flat foot Prolonged standing Fat pad atrophy Tight triceps surae Repetitive strength imbalances Over use may cause microtears and inflammation Congenital problems such as Pescavus and Pesplanus Obesity Reiters disease,Ankylosing spondylitis,Diffuse idiopathic skeletal hyperostosis weight bearing endurance activity (dancing, running)
- Plantar fascitis have more tenderness in the plantar fascia when it is stretched and less tenderness when the fascia is relaxed. The plantar fascitis test uses this property to diagnose patients with plantar fascitis. To perform this test, first stretch plantar fascia. Then use your thumb or finger to feel the plantar fascia. If plantar fascia is tender, then try the same maneuver with plantar fascia relaxed. If pushing the stretched plantar fascia causes more tenderness than pushing on the relaxed plantar fascia, then the plantar fascia is likely the source of the pain and the patient have plantar fascitis
- Mri may be useful for surgical planning X-rays of patient with heel pain sometimes reveal a calcification of the plantar aponeurosis at the origin on the calcaneus, commonly referred to as a heel spur BONE SCAN: It show increase uptake at the calcaneus RHEUMATOLOGIC SCREENING: It can be important to rule out inflammatory arthrides.
- Corticosteroid injections can lead to fat pad atrophy or plantar fascia rupture
- Two bursae are located just superior to the insertion of the Achilles (calcaneal) tendon. Anterior or deep to the tendon is the retrocalcaneal (subtendinous) bursa, which is located between the Achilles tendon and the calcaneus. Posterior or superficial to the Achilles tendon is the subcutaneous calcaneal bursa, also called the Achilles bursa. This bursa is located between the skin and posterior aspect of the distal Achilles tendon
- Haglund deformity an enlargement of the posterosuperior tuberosity of the calcaneus
- Chronic pain and tenderness directly over the fat pad under the heel sometimes follows a direct blow to the area, e.g. in a fall from a height. The condition is also seen in athletes and has been attributed variously to separation of the fat pad from the bone, loss of its normal shock-absorbing effect and atrophy. Non-specific ‘inflammation’ has also been blamed. Treatment is palliative: wearing soft-soled shoes or shock-absorbing heel cups, foot baths and anti-inflammatory agents.