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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
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:
8.
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.
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
13.
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
15.
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
17.
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
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
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
30.
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
Notes de l'éditeur
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.
