Heel Pain (Plantar Fasciitis) Treatment Protocol - Worcester, MA
HEEL PAIN – “For the Record” A Community Presentation
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Transcript of HEEL PAIN – “For the Record” A Community Presentation
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
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James A. Marks DPM, FACFAS, FAPWCA
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?
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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
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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
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Buchbinder, R. N Eng J Med. 2004; 350: 2159-66.
APMA FOOT AILMENTS SURVEY JANUARY 2009
James A Marks, DPM, FACFAS, FAPWCA www.pennfoot.com
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
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THERE ARE MANY CAUSES
MechanicalNeurologicalRheumatologicalTraumaticInfectiousMetabolicNeoplastic
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PRIMARY CAUSESMechanical
primarily plantar fasciosis
Neurological primarily nerve entrapment
Rheumatological primarily seronegative arthritides
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MECHANICALPlantar fasciitisHeel Spur SyndromeInferior calcaneal bursitisHeel bruise “Policeman’s Heel”Stress FractureFat pad pathologyChronic compartment syndrome
James A Marks, DPM, FACFAS, FAPWCAwww.pennfoot.com
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
James A Marks, DPM, FACFAS, FAPWCAwww.pennfoot.com
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
James A. Marks DPM, FACFAS, FAPWCA
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MAKING the DIAGNOSISHistoryPhysicalImagingBlood tests
For inflammatory arthritisNerve conduction studies
For nerve pathology
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HISTORYLocation of pain?Nature of pain?Duration of pain?When does the pain occur?Age, physical make-up, activities?
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KNOWING PAINLocation 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?
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PHYSICAL EXAMPalpationRange of motionFunctional testing
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MAXIMAL TENDERNESS
(1) plantar fasciitis
(2) entrapment of the
first branch of the
lateral plantar nerve
(3) heel pain syndrome
(4) fat pad disorders
James A. Marks DPM, FACFAS, FAPWCA
PALPATION
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PALPATION
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IMAGINGPlain film X-rays
Generally the starting pointBone scans
Increased bone turnoverUltrasonography
Soft tissue problemsCT Scan MRI www.pennfoot.com
IMAGING
Plain Films www.pennfoot.com
IMAGING
Tech Bone Scan
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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
James A. Marks DPM, FACFAS, FAPWCA
EVER FELT LIKE YOU'RE IN A PICKLE?
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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
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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!
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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
James A. Marks DPM, FACFAS, FAPWCA
SECOND VISITYOU 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
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James A. Marks DPM, FACFAS, FAPWCA
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
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James A. Marks DPM, FACFAS, FAPWCA
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
James A. Marks DPM, FACFAS, FAPWCA www.pennfoot.com
NEW TREATMENT OPTIONS
Shockwave treatmentTopaz (Coblation)
Platelet Rich Plasma Injection
TAKE HOME MESSAGE
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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