41 ST Annual Goldfarb Clinical Conference Valley Forge Casino Resort King of Prussia, PA James A...

HEEL PAIN – “For the Record”

A Community Presentation41ST Annual Goldfarb Clinical

ConferenceValley Forge Casino Resort

King of Prussia, PA

James A Marks, DPM, FACFAS, FAPWCA Medical Director, The Wound & Skin Healing Center of Washington Health SystemFoot and Ankle Specialists / Washington Physicians Group

11-08-13

PRESENTER DISCLOSURE

Employed by Washington Health System & Washington Physicians GroupSpeakers’ Bureau for Shire Regenerative MedicineFather of 4 ~ Luca’s Grandfather

“Well done is better than well said.” ~ Benjamin Franklin

James A. Marks DPM, FACFAS, FAPWCA

1984 PHOP RESIDENTS

TODAY’S OBJECTIVES

Summarize the most common causes and

treatment of plantar heel pain syndrome Provide a unique educational

experience for your public audience

Expand your current referral pathways within your community

www.pennfoot.com


James A Marks, DPM Fellow, American College of Foot

and Ankle Surgeons

HEEL PAINAMERICA’S #1 FOOT

AILMENT

OBJECTIVES OF THIS LECTURE

Causes of Heel painHow to self treat before calling a PodiatristHeel pain work-upDiscuss treatment New treatmentsSurgical options

James A Marks, DPM, FACFAS, FAPWCA www.pennfoot.com

DOC, THIS IS WHERE IT HURTS!

James A Marks, DPM, FACFAS, FAPWCA

WHY?


YOU ARE NOT ALONE

HEEL PAIN 2 million Americans each year 90% of heel pain patients respond in 6 wks

to 6 mo Commonly shared risk factors: overly tight

calf muscle, poor shoe choices, weight gain, barefoot walking, or hard work surface.

3 times your body weight is transferred into your heel area with each step

James A Marks, DPM, FACFAS, FAPWCA

www.pennfoot.com

COMMON RISK FACTORS

Obesity or sudden weight gain Tight Achilles tendon Change in walking or running

habits Poor cushioning in shoes Change in walking or running

surface Job that requires prolonged

time standing/walking Excessive pronation of the foot

www.pennfoot.com

Buchbinder, R. N Eng J Med. 2004; 350: 2159-66.

APMA FOOT AILMENTS SURVEY JANUARY 2009


APMA FOOT AILMENTS SURVEY JANUARY 2009

Kelton Research 1,082 surveyed James A Marks, DPM, FACFAS, FAPWCA

HEEL PAIN SYNDROME

Plantar fasciitis/iosisPlantar fibromatosisStress fractureNerve entrapmentTraumaCalcaneal apophysitisTarsal tunnel syndromeCalcaneal bone cysts / tumors


THERE ARE MANY CAUSES

MechanicalNeurologicalRheumatologicalTraumaticInfectiousMetabolicNeoplastic

James A Marks, DPM, FACFAS, FAPWCAwww.pennfoot.com

PRIMARY CAUSES

Mechanical primarily plantar fasciosis

Neurological primarily nerve entrapment

Rheumatological primarily seronegative arthritides

www.pennfoot.com James A Marks, DPM, FACFAS, FAPWCA

MECHANICAL

Plantar fasciitisHeel Spur SyndromeInferior calcaneal bursitisHeel bruise “Policeman’s Heel”Stress FractureFat pad pathologyChronic compartment syndrome


The Truth about Heel Spurs

Calcaneal spurs are an adaptive response to vertical compression of the heel rather than longitudinal traction of the plantar fascia

Spurs do not grow in the plantar fascia

Degenerative changes due to stress reaction / micro-fractures

Kumai and Benjamin, J Rheumatol, 2002


PLANTAR FASCIITIS* Pain on standing,

especially after periods of inactivity or sleep

Pain subsides, returns w activity

Pain related to footwear – can be worse in flat shoes w no support

Radiating pain to the arch & toes

In later stages, pain may persist/progress

throughout the day Pain varies in character:

dull aching, “bruised” feeling. Burning or tingling, numbness, or sharp pain, may indicate local nerve irritation

*First described by Woods, 1812


www.pennfoot.com

MAKING the DIAGNOSIS

HistoryPhysicalImagingBlood tests

For inflammatory arthritisNerve conduction studies

For nerve pathology


HISTORY

Location of pain?Nature of pain?Duration of pain?When does the pain occur?Age, physical make-up, activities?


KNOWING PAIN

Location with what structures are in the area

Is the pain sharp or dull or burning?

Is the pain acute or chronic?Does it occur after activity?Related to a person’s weight or

activity?What relieves the pain?What has the patient already

tried?


PHYSICAL EXAM

PalpationRange of motionFunctional testing


MAXIMAL TENDERNESS

(1) plantar fasciitis

(2) entrapment of the

first branch of the

lateral plantar nerve

(3) heel pain syndrome

(4) fat pad disorders


PALPATION


IMAGING

Plain film X-rays Generally the starting point

Bone scans Increased bone turnover

Ultrasonography Soft tissue problems

CT Scan MRI

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IMAGING

Plain Films

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IMAGING

Tech Bone Scan


IMAGING

MRI: T1 MRI: T2 fat suppressed sagittal image abnormal signal in proximal plantar fascia and bone marrow edema www.pennfoot.com James A Marks, DPM, FACFAS, FAPWCA

TREATMENT

http://www.podiatrytoday.com/files/imagecache/normal/white1.png

http://www.amazon.com/Wonder-Spur-Soft-Silicone-Heel-Cup/dp/images/B000UDXR9I/ref=dp_image_x_0?ie=UTF8&s=sporting-goods&img=0&color_name=x

http://www.amazon.com/gp/product/images/B001EPQ5RW/ref=dp_image_0?ie=UTF8&n=3760901&s=hpc

http://www.amazon.com/FootSmart-Adjustable-Heel-Lift/dp/images/B00021Z3TK/ref=dp_image_2_0?ie=UTF8&s=hpc&img=0&color_name=2


EVER FELT LIKE YOU'RE IN A PICKLE?

www.pennfoot.com

We Are…WHS/Foot & Ankle

Specialists

www.pennfoot.com James A. Marks DPM, FACFAS, FAPWCA

SELF TREATMENT Avoid walking

barefoot Shoe modifications Icing and rest Stretching Night or resting splint Supplemental arch

support (OTC vs. custom

orthotics) Oral & Topical NSAIDS Seek out Podiatrist if

not better in 4 weeks

www.pennfoot.com

PROPER SHOE GEAR

Throw out all “bad” shoes Too soft not always good Crocs good for certain feet Running shoe the best Avoid flat shoes Shoes to Avoid:

Flip flops!

www.pennfoot.com

FIRST VISITNSAIDsCortisone injection ???Air-heel brace, heel cup, heel lifts

OTC Orthotics, etc. Patient education:Elimination of barefoot walkingActivity alteration - RICE after activity Stretching of plantar fascia & Achilles

tendonProper shoe gearWeight loss program & Lifestyle

changeReappoint in 3 weeks


SECOND VISIT

YOU ARE NOW 3-4 WEEKS PAIN LEVEL 5 OR

Reassess exam and review testing results

Patient education reinforcement Physical therapy Cortisone injectionNSAID adjustment (oral & topical)Night splintProper shoe gear Off-loading DME products

www.pennfoot.com


THIRD VISIT

YOU ARE NOW 7-8 WEEKS PAIN LEVEL 5 OR :

Reassess exam and chief complaint Patient education reinforcementReassess effectiveness of PTCortisone injection ??NSAID adjustment (oral & topical) Rx: Custom Molded OrthoticsSpecial testing: MRI, Bone scan,

EMG/NCVReappoint in 6-8 weeks

www.pennfoot.com


FOURTH VISIT

YOU ARE NOW 3-6 MONTHS PAIN LEVEL 5 OR :

Reassess exam & chief complaintAny additional testing needed? Patient education reinforcementCortisone injection ??NSAID adjustment (oral & topical) Immobilization Surgical intervention Referral


www.pennfoot.com

NEW TREATMENT OPTIONS

Shockwave treatmentTopaz (Coblation)

Platelet Rich Plasma Injection

TAKE HOME MESSAGE


Live life with no regrets…

THANK YOUFor more information…

724-222-5635Monday through Friday

8 am – 4:30 pm Wilfred R. Cameron Wellness Center

208 Wellness Way, Bldg.1

41 ST Annual Goldfarb Clinical Conference Valley Forge Casino Resort King of Prussia, PA James A...

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