Heel painMr Derek ParkConsultant Orthopaedic Surgeon (Foot & Ankle)

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

Plantar heel painBackgroundIllustrative caseDifferential diagnosisTreatment options EvidenceCurrent management concepts

Mr DS51 yr old, commercial manager, triathlon enthusiast6m Hx plantar heel painworse 1st thing in the morning, prolonged standingno radiculopathy, no neuropathy (DM/Alcohol)tried: insoles, night splints, calf stretches 3 months

Plantar heel painCommon conditionAffects 1:10 adults Often self-limitingRecalcitrant cases can be challenging

Anatomy

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

AnatomyType I collagenSupports medial longitudinal arch & aids propulsion, dissipates forces + stresses during gait and loadingVisco-elastic propertyRuffini & Pacinian corpuscles = mechanoreceptorsHyaluronan (HA) = proximally

Anatomy

Biomechanics

Biomechanics

Where is the pain

Differential diagnosisNervesciatica; tarsal tunnel syndrome, FBLPN (N to ADQ)Soft tissuefibromatosis, bursitis, bruise, fat-pad atrophyBonestress fracture, infection, tumour, Pagets

HistoryPlantar heel painNo traumaPain on 1st stepsWarms upReturns with prolonged WB

Examination

heel compression for stress fxTinels test for tarsal tunnel or ADQ

EnthesopathyAssociated with inflammatory arthropathyHeel spurs often foundMedical management of inflammation

Mr DS51 yr old, commercial manager, triathlon enthusiast6m Hx plantar heel painworse 1st thing in the morning, prolonged standingno radiculopathy, no neuropathy (DM/Alcohol)tried: insoles, night splints, calf stretches 3 months

Investigation

Night splint

Medial arch foot orthoses

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

TreatmentSteroid injectionrisk fat atrophyrisk of ruptureUltrasound guidedJudicious useESWT

TreatmentAOFAS position statement:Dont 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

EvidenceMarginal gains onlysteroid injection - short term & small degreeorthoses - prolonged standinglimited evidence that stretching & heel pads are better than custom-made orthosesESWT +ve but small effectCrawford & Thomson Cochrane 2000, 2003Thomson & Crawford BMC 2005

TreatmentGP - Physio - stretches - US - insoles - NSAIDS - taping - GP - MSK Triage - Acupuncture - Orthopaedic F&A surgeonOrtho F&A clinic - more physio - gastroc/PF stretches - imaging - review - desperate measures - pain clinic - CBT .

Mr DS

AssessmentIdeal one-stop service: diagnosis, imaging, treatmentDetermine gastrocnemius tightness: Silfverskild test

Gastrocnemius contractureRestricted ankle dorsiflexion associated withchronic TA tendinopathyplantar heel painacquired flat foot deformitymidfoot OAmetatarsalgiaDigiovanni et al 2002 JBJSAm

TreatmentTA stretching, technique important

Gastroc lengthening

Gastroc lengthening

Classic Strayer lengthening

PMGRInternational meeting of the French Foot societies, Toulouse 2006

The role of gastrocnemius contractureAssociation between isolated gastrocnemius contracture and forefoot/hindfoot problems - DiGiovanni JBJS 2002, Patel & DiGiovanni FAI 2011Spectrum midfoot/arch collapse - J Anderson, D Bohay et al

Tibial nerve

Semimembranosus

Short saphenous vein

MidlineMedial Sural Cutaneous nerve

Common Peroneal nerve

Lateral Sural Cutaneous nerve

AnatomyHamilton et al. FAI 2009Medial approach is free from nervous structures

Anatomy

Hamilton et al. FAI 2009Medial head x-sectional area 2.4x Lateral

Technique

Technique

Fossa is medial2.5 cm incision

ProneLeft Leg

Technique

Surgeons viewProneRight Leg

Technique

Surgeons view

Technique

Surgeons view

Technique

Calf LengtheningPMGRLevel 4.5

PMGRHeel pain clinicGastrocnemius contracture and its role in plantar fasciitis and Achilles tendinopathySpecific indicationsStress ongoing management with eccentric stretching +/- ESWT

Prospective consecutive series of 21 heels (17 patients) with recalcitrant plantar fasciitisSymptom duration 12 months to 6 yearsPositive Silfverskilds testConfirmed with imaging (MRI, USS or bone scan)Average 24 months follow up (8-36 months)Outcome measure: 5 pt Likert scale, calf weakness, satisfactionResults - PMGR in recalcitrant plantar fasciitisAbbassian et al. FAI Jan 2012

88% recommend surgeryNo weakness1 minor wound complication Abbassian et al. FAI Jan 2012

Mr DSSteroid injectionESWTModerate improvement 30-40%Next steps

Personal approachClinical assessment - include XRs, USS to define pathology and PF thickness, r/o other pathology6 months physio (lower limb team)If gastroc tight - stretch - PMGRIf not - ESWTConsider steroid, PRP, ABT, HA, dry needling, acupuncture, topazDefer surgery

SummaryAim for logical approach, step-wise management, and one-stop modelThink of tight calvesConsider non-operative measures alwaysEvidence

ReferencesHicks JH. The mechanics of the foot. II. The plantar aponeurosis and the arch. J Anat. 1954 Jan;88(1):25-30Bolgla LA, Malone TR. Plantar fasciitis and the windlass mechanism: a biomechanical link to clinical practiceJ Athl Train. 2004 Jan;39(1):77-82Shaw HM, Vzquez OT, McGonagle D, Bydder G, Santer RM, Benjamin M. Development of the human Achilles tendon enthesis organ. J Anat. 2008 Dec;213(6):718-24Pavan 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):905-11Stecco 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):665-76Martin 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