Welcome to the Podiatry Arena forums

You are currently viewing our podiatry forum as a guest which gives you limited access to view all podiatry discussions and access our other features. By joining our free global community of Podiatrists and other interested foot health care professionals you will have access to post podiatry topics (answer and ask questions), communicate privately with other members, upload content, view attachments, receive a weekly email update of new discussions, access other special features. Registered users do not get displayed the advertisements in posted messages. Registration is fast, simple and absolutely free so please, join our global Podiatry community today!

  1. Everything that you are ever going to want to know about running shoes: Running Shoes Boot Camp Online, for taking it to the next level? See here for more.
    Dismiss Notice
  2. Have you considered the Critical Thinking and Skeptical Boot Camp, for taking it to the next level? See here for more.
    Dismiss Notice
  3. Have you considered the Clinical Biomechanics Boot Camp Online, for taking it to the next level? See here for more.
    Dismiss Notice
Dismiss Notice
Have you considered the Clinical Biomechanics Boot Camp Online, for taking it to the next level? See here for more.
Dismiss Notice
Have you liked us on Facebook to get our updates? Please do. Click here for our Facebook page.
Dismiss Notice
Do you get the weekly newsletter that Podiatry Arena sends out to update everybody? If not, click here to organise this.

Displaced Plantar Fat Pad

Discussion in 'Foot Surgery' started by WalkWithoutPain, Nov 7, 2014.

  1. WalkWithoutPain

    WalkWithoutPain Active Member


    Members do not see these Ads. Sign Up.
    Hi Folks. I have a patient with medially displaced plantar calc fat pad. It is very painful but managed moderately well with taping for the past four weeks. The skin and other tissues are intact, it just seems to have slipped sideways. There is a history of corticosteroid injection into the area. We had been waiting on her visit to an orthopaedic foot surgeon but ultimately he offered no treatment. (He was delighted to see such a rare specimen though - all but asking the patient for her autograph). Has anyone got any advice for me in managing the condition or a surgeon in Brisbane (even Australia) who might be of help? I am thinking plastic surgeon at this stage. Appreciate any help from the arena. Stephanie
     
  2. Fraoch

    Fraoch Active Member

    I had a relatively similar case following a botched cancer surgery. The client tried various types of tape (until the best solution was found), then we taped from the squished side back to the "ripped" side and then a Tulli heel cup to hold all that together. That was the best we could do. No surgeon in our city would touch the client.
     
  3. WalkWithoutPain

    WalkWithoutPain Active Member

    Thanks for the reply. I was afraid that might be the case.
     
  4. Mart

    Mart Well-Known Member

    Hi

    Are you able to provide some more information? Age, comorbidity, activity, occupation? What was CSI done for? Can you palpate motion within the plantar fibro-fatty pad? Where does the pain seem located? Was there any imaging done? Do you think that fat shifts when weight-bearing or is there a a less or more compliant mass present such as a bursa or lipoma which may give the impression of generalized motion of plantar fibro-fatty pad.?Do you have a theory about where pain is generated and what might be causing pain? A video of the weight-bearing behavior of the plantar fibro-fatty pad would be interesting, even better an ultrasound video showing the "flow" of the fat compartments with probe pressure.

    Cheers

    Martin

    Foot and Ankle Clinic
    1365 Grant Ave.
    Winnipeg Manitoba R3M 1Z8
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  5. WalkWithoutPain

    WalkWithoutPain Active Member

    Hi - Thanks for your reply: The patient is a female approx 50 years old. She is around 5'2" with a heavy build. She has a Hx of 1 prior corticosteroid injection into the heel for p fasc, 5+ years ago. She has recently had back surgery (around 6 months ago) which was preceded by a longish period of rest. After healing, the surgeon instructed her to walk. She reports walking through a park when the searing pain occurred. One step normal, next step bad with no event identified. The local doc treated her with 5 or 6 courses of antibiotics - name unknown - but the sort requiring health department approval prior to ordering so maybe piperacillin or similar. I did not see her until the doc declared the infection cleared. The patient reports no redness, weeping, discharge, pus, or even opening in the skin apart from her normal heel cracks. The pain did not vary between te time she was untreated, on anti-bacterials, or declared clear of infection. I can't say with certainty as I did not see her (and the doc in question is a reasonable one) but I am treating the reported infection as a red herring. The only reduction in pain from day 1 was with taping.

    The area of pain is all of the plantar calc area with the most painful being the area where a bulge of tissue extrudes medially from the calc. One can place a finger dorsal to it and plantar to in and have a soft tissue bulge of ~ 15 mm. Pinching it is painful. The other foot is unremarkably normal (no bulge). The doc has has x rays done which shows nothing. Ultrasound (specifically asked to have the fat pad examined) shows a retro calc bursa and swelling in the Kager's triangle. The radiologist notes that the fat pad looks normal. There is no defect in the pad in the mid calc area so I think that it is not cleft through the middle. There also does not seem to be a deficiency of the pad from the lateral side. I think that the pad may be intact but slipped? There is no indication from the radiologist of a lipoma or bursa. On standing the pad bulges medially. I can chase up the ultrasound images, films and take some photos. A video should also be possible. I see her again in about 5 days.

    Thank you again for the interest, I would like to be able to offer some guidance for her treatment.
     
  6. Mart

    Mart Well-Known Member

    Hi

    My impression is that symptoms were very sudden onset - is that true and have they changed?. How did you apply strapping and what effect do you believe this has?

    What you are describing sounds like a piezogenic papule; if you are unfamiliar with this phenomenon look at

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3853915/

    do you think this is likely?

    Regardless I wonder if your patient has more than one problem. Some further thoughts:

    What is quality and nature of pain?

    Does she have rest pain? Given recent surgical HX - have you ruled out radicular contribution?

    Is there worst pain on rising from bed in morning? Did radiologist comment on plantar aponeurosis?

    Is pain worse towards end of day? Is there pain with lateral compression across calcaneus which might suggest bone edema?

    Is there any retrocalcaneal pain?

    Cheers

    Martin

    Foot and Ankle Clinic
    1365 Grant Ave.
    Winnipeg Manitoba R3M 1Z8
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  7. WalkWithoutPain

    WalkWithoutPain Active Member

    My impression is that symptoms were very sudden onset - is that true and have they changed?. How did you apply strapping and what effect do you believe this has?
    Yes sudden onset - set out on that particular walk ok but could not complete it.
    What you are describing sounds like a piezogenic papule; if you are unfamiliar with this phenomenon look at

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3853915/

    do you think this is likely? No - the author there describes epidermal polyp like lesions of up to 4 mm. This is a distinct sub dermal mass, thickness of 15 mm , length = to plantar calc area. The taping i used was a long teardrop shape, down the lateral border, around the heel then with lateral tension back to finish on lateral pma. Essentially restricting the medial bulge of the mass under weight bearing pressure. Pain has gone to a 4/10 from the base level of 10/10. I believe that the pain is quite severe.

    Regardless I wonder if your patient has more than one problem. Some further thoughts:

    Does she have rest pain? Given recent surgical HX - have you ruled out radicular contribution? There is no pain proximal to this in the distribution of the nerve. The pain occurred some months after surgery and went from 0 to 10 in a step - no indication of neurological / rsds (or whatever it is called in your part of the world) to my mind. No rest pain. No tumors on x ray or u/sound.

    Is there worst pain on rising from bed in morning? Did radiologist comment on plantar aponeurosis? The aponeurosis is sl thickened. Pain is equivalent with each step. No pain on compression of the calc above the bulge of tissue.

    Is pain worse towards end of day? Is there pain with lateral compression across calcaneus which might suggest bone edema?

    Is there any retrocalcaneal pain? Pain there is not part of her complaint. Slight pain when I palpated the site of the bursa but pales in comparison to the primary area.

    I have uploaded a (very rudimentary) diagram of the foot to give an idea of scale. Can take a photo at next meeting <a href="http://tinypic.com?ref=1r2of9" target="_blank"><img src="http://i58.tinypic.com/1r2of9.jpg" border="0" alt="TinyPic"></a>

    I do that you for your interest and advice. I know it is hard without visuals. Stephanie
     
  8. Mart

    Mart Well-Known Member

    Hi Stephanie

    Does the mass seem associated with the course of the proximal aspect of the medial plantar vein - was ther any comment regarding vein patency on radiologist US report to rule out thrombosis?

    Interesting case

    cheers Martin

    Send from my Iphone
     
  9. Mart

    Mart Well-Known Member

    Hi Stephanie

    you may have come across this blog which initiated anecdotes around using graftjacket implants to manage plantar fibro-fatty pad dysfunction - it provides some interesting comments.

    http://www.mdnews.com/news/2010_03/...l-surgical-treatment-for-fat-pad-atrophy.aspx

    I am very curious about the appearance of the area and that mass seemed to occur spontaneously. If there is truly a breach of the superficial macro chambers of the calcaneal plantar fibro-fatty pad allowing herniation of the deep macro chambers I would imagine that this would be sonographically visible dynamically with probe pressure.

    If there is reasonable exclusion of DDx other than plantar fibro-fatty pad dysfunction and you have good rapport with radiologist it would be interesting to repeat sonography and get some ultrasound video of the ROI. I have experience performing foot and ankle ultrasound exams and would be interested to be involved in a discussion with radiologist if that might be helpful.

    In mean time I look forward to seeing a visual video of the heel area.

    Last question - was pt aware of the mass and if so was visibility associated with the onset of pain?

    Cheers

    Martin

    Foot and Ankle Clinic
    1365 Grant Ave.
    Winnipeg Manitoba R3M 1Z8
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  10. WalkWithoutPain

    WalkWithoutPain Active Member

    Does the mass seem associated with the course of the proximal aspect of the medial plantar vein - was ther any comment regarding vein patency on radiologist US report to rule out thrombosis?

    Hi Mart. The mass is in the area of the vein. Interesting point, I will revisit the scans. No mention of that in the radiologist reoport, though.
    you may have come across this blog which initiated anecdotes around using graftjacket implants to manage plantar fibro-fatty pad dysfunction - it provides some interesting comments.

    http://www.mdnews.com/news/2010_03/0...d-atrophy.aspx

    I am very curious about the appearance of the area and that mass seemed to occur spontaneously. If there is truly a breach of the superficial macro chambers of the calcaneal plantar fibro-fatty pad allowing herniation of the deep macro chambers I would imagine that this would be sonographically visible dynamically with probe pressure.

    If there is reasonable exclusion of DDx other than plantar fibro-fatty pad dysfunction and you have good rapport with radiologist it would be interesting to repeat sonography and get some ultrasound video of the ROI. I have experience performing foot and ankle ultrasound exams and would be interested to be involved in a discussion with radiologist if that might be helpful. Nice though, I think that this could be possible

    In mean time I look forward to seeing a visual video of the heel area.

    Last question - was pt aware of the mass and if so was visibility associated with the onset of pain?
    I can't say. She certainly was aware of the bulge when I first saw her. I do not know if she can be sure that it was not present before. And afetr all, haven't we all had patients who swear their stage 3 bunion wasnt there last week? I will add this to my list of questions for Saturday's visit. Thank you again for your interest and your input.
     
  11. WalkWithoutPain

    WalkWithoutPain Active Member

  12. Mart

    Mart Well-Known Member

    Hi Stephanie

    If there are Dicom files please could you email me them - looks like the sequences were weight-bearing is that true? Also are the T2 sequences fat saturated ? That would rule out bone edema as likely root of pain.

    If you only have film copy can you post a sagittal view so that we can see if there is an enthesite and it relationship to plantar fibro-fatty pad.


    Is the pain localized to the area medial to the medial process of calcaneal tuberosity?

    What does the heel look like when non weight-bearing?

    Cheers

    Martin

    Foot and Ankle Clinic
    1365 Grant Ave.
    Winnipeg Manitoba R3M 1Z8
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  13. WalkWithoutPain

    WalkWithoutPain Active Member

    If there are Dicom files please could you email me them - looks like the sequences were weight-bearing is that true? Also are the T2 sequences fat saturated ? That would rule out bone edema as likely root of pain. I don't know the answer to that but can say that pressure on the soft tissue (missing the bone) is painful and squeezing the bone above the soft tissue is not painful.

    If you only have film copy can you post a sagittal view so that we can see if there is an enthesite and it relationship to plantar fibro-fatty pad.


    Is the pain localized to the area medial to the medial process of calcaneal tuberosity? No, quite general, worst area is themedial bulge seen positioned between my fingers in thelast image

    What does the heel look like when non weight-bearing?

    Very little change - still bulges. can be seen on the video image of the foot lowering.
     
Loading...

Share This Page