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Forefoot Equinus...and calcaneal pain.

Discussion in 'Biomechanics, Sports and Foot orthoses' started by manmantis, Jun 7, 2011.

  1. manmantis

    manmantis Active Member

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    I have a good friend who has recently begun seeing me as a patient. He has been managed by various podiatrists over the years, with middling levels of success.

    He is 42 and has a long history of plantar fasciitis, it flares up every couple of years, is made bearable and then gradually subsides. He gets persistent discomfort in his 1st MtP jt. He also suffers frequent calf discomfort & resting cramps. It is also worth noting that he had a prolonged battle with Severs disease from about 10-15 years old, It was poorly managed and he was too stubborn to resist high impact activity despite the pain it caused him at the time.

    He is an outdoor ed teacher, a very active bushwalker & cyclist, and does pilates 3 times a week. He used to be a good club runner (33min 10K) until his feet became too painful to allow him to continue (about 10 years ago).

    He came to me last month with yet another bout of plantar fasciitis (PF) which developed while we were doing some pack training before we were due to walk the South Coast track here in Tasmania (he ultimately had to pull out before we left). I gave him some standard advice before I left which seemed to have the desired effects. However he complained of an additional calcaneal tenderness & "sharp" pain which he hadn't experienced before.

    I saw him today for a full appointment (as opposed to beer glass "diagnosis" & advice). Examination showed an internally rotated hip position. SLR was excellent. No knee discomfort. Ankle ROM was good. However Gastrocs & Soleus felt quite "solid". STJ inversion/eversion was unremarkable.

    He has a marked bilateral Forefoot Equinus. This corrects with moderate dorsifexion force. He fails the lunge test, as he is obviously pre-loading his achilles just to correct the equinus and therefore reducing ankle dorsiflexion (At least that's my understanding of the mechanics). During gait he abducts both feet throughout, he offloads both heels pretty quickly, and feet pronate early & remain so until he rolls off the medial border of his hallux (functional hallux limitus noted).

    The plantar fascia was tender to palpate, and symptoms consistent with PF...albeit that this had improved with ice/massage/stretches and a reduction in high impact activity.

    The sharp pain I reproduced in both calcaneus with medial/lateral compression around the posterior margin. There was no discomfort around the insertion of achilles or in the achilles itself. In fact, were it not for him being 42 I could have described the pain as being consistent with Severs disease. I considered Tarsal Tunnel syndrome, but Tinels sign was negative (I accept this could be tester error however).

    I have issued him with some 6mm EVA heel lifts to add to his pretty neutral EVA orthotics and sent him for U/S scan of plantar fascia & medial calcaneus...and also requested some plain X-ray.

    It's worth noting that he has worn orthotics continuously for many years. Early polyprop devices were not tolerated well as they were painful through MLA. 1st ray cutouts were helpful however in managing 1st MtP discomfort. More recently he has been using EVA devices with a raised met dome or reverse mortons extension. He finds these moderately useful but 1st MtP jt & Calf discomfort are never far away.

    Any thoughts/suggestions for what the calcaneal pain might be? Calcaneal stress #? Tarsal Tunnel syndrome that I'm failing to dx? Some hitherto unknown long-term Severs complication?

    Cheers in advance to all suggestions, and apologies for the stream-of-conciousness case presentation.
  2. Sound like too much tension in the Gastroc/Sol complex is the Root of all issue here.

    heel lifts
    etc etc

    as for what the calc problem could be hopefully your diagnostic tests will tell, but I would bet from your history Tension in the Gastroc/Sol Complex as the underlying Cause.
  3. manmantis

    manmantis Active Member

    Yep, I accept that. My treatment/advice so far has been directed in this direction. He's put a lot of work in over the last month to stretch Gastrocs/Soleus, use of an iced bottle to roll under the fascia and almost daily calf massage from a masseur (!!). This has all reduced the PF pain. But the calcaneal pain has remained constant.

    I just can't connect this pain to a dx. If it was Tarsal Tunnel syndrome, wouldn't the pain be more plantar or just medial calc? Why then lateral calc pain? If it was achilles insertional issue wouldn't it be posterior/superior pain? If Stress # wouldn't plantar calc be as painful to palpate as medial/lateral?

    I'm interested to see the X-ray & U/S but I usually like these to confirm not uncover a dx.
  4. manmantis

    manmantis Active Member

    Just out of interest. Just considering the Forefoot Equinus on its own. Is there a method of reducing a forefoot equinus long-term?

    I mean, I consistenly use heel lifts to reduce problems associated with this foot position. But can we progress these people to a point where they no longer require heel lifts? Is there a mobilisation technique for example?

    Or is it there to stay once developed?
  5. Griff

    Griff Moderator

    Calcaneal fat pad irritation?
  6. efuller

    efuller MVP

    A couple of questions:
    What do you mean by the forefoot equinus corrects. Is it at rest, in the exam chair, the forefoot plantar flexes on the rearfoot and then when you push lightly on the forefoot you can dorsiflex the forefoot to achieve, low arch, or average arch, or high arch? When he is standing how high is his arch?

    Could you describe the failed lunge test. i.e. When attempting a lunge he shows.... (tibia angle to ground?)

    What is the ankle dorsiflexion with knee flexed and extended with the forefoot loaded when he is non weight bearing?

    Often in a flexible cavus foot the cast of the foot will have a really high arch. Too high when compared to the weight bearing arch height of the foot. I have casted these patients with pressure under the first ray to dorsiflex it and the forefoot to get a more reasonable arch height.

  7. manmantis

    manmantis Active Member

    Sorry, I should have specified non-weightbearing exam. Moderate force to dorsiflex the forefoot against the rearfoot allows correction with a low arch. Weightbearing arch height is also low. Ankle dorsiflexion is excellent with knee extended or flexed (I no longer grade using "10 degrees" as a measure, but ROM easily achieves that). It "feels" tighter with gastrocs, but I can still get "average" ankle dorsiflexion non-weightbearing.

    I don't have my notes to hand (and won't be ble to access until Friday now), but I usually grade a lunge test as a "fail" if the patient can't reach a tibial angle of 30 degrees. (I'm probably being conservative with this as I've seen 35 degrees quoted as a cut-off).

    I am quite certain that the early polyprop devices were too high and too hard for the weight-bearing arch. He is happier by far with the more recent EVA devices although that is certainly because they have a lower arch fill.

    Thanks for your thoughts so far.

  8. CraigT

    CraigT Well-Known Member

    Hi Julian
    I would consider trigger points in the soleus as a potential cause of the heel pain. Has he ever had dry needling done?
    Also based on your description I would say that the fit of the orthosis would be critical. I usually use a poly device for this type of foot, but the fit must be very good and accommodate soft tissue- particularly the plantar fascia. The device would have to have a groove for the plantar fascia and it would have to be in the correct place. Even the addition of a soft cover can mess up the fit- I have often seen an improvement in comfort with the removal of a soft cover...
  9. Ian Harvey

    Ian Harvey Active Member

    Craig said
    I agree, and always check gastrocs and soleus whenever a case of PF presents. Even if you can't find a definite trigger point, you may detect tight bands within the muscles.

    Had a case today. Layed his calves on a massage pad for a few minutes and he stood up pain free. I often include either positional release or machine massage to release painful structures on the plantar foot. Whichever method used, I always follow up immediately with PNF stretches and ask the patient to perform slow and careful heel drop exercises on a stair. I usually review after a week, and usually the patient is much improved. Sometimes use acupuncture instead on gastrosoleus, but PNF and heel drops remain the same. Doesn't always work, but has a high success rate. I only use orthoses if problems persist.
    Hope this helps,
  10. Frederick George

    Frederick George Active Member

    Your patient has bone marrow oedema, evidenced by pain on compressing the calcaneus. After long standing plantar fasciitis/heel spur, the inflammation causes the oedema.
    This was considered to be a myth until fairly recently, when it could be seen in scans.
    In 1983 Chinese orthopaedic surgeons in Beijing presented a study to us where they measured the intracalcaneal pressure (an 18 guage needle thrust into the calcaneus, with a manometer attached), pre and post op calcaneal decompression (6 holes drilled into the lateral calcaneus. They left the heel spur and plantar fascia alone.
    The procedure was successful, and there was a positive relationship between the improvement in symptoms and the amount of reduction in pressure, from patient to patient.
    This surgical procedure had previously been done in Europe, US, and Egypt, with generially good results.
    There is some supposition that the reason heel spur excision works is because it allows the calcaneus, a vast vascular void, to decompress.
    I have found that when calcaneal oedema exists, along with plantar fasciotomy and heel spur excision (if present), the calcaneus can be decompressed by drilling 2 oblique holes the length of the body of the calcaneus (a K-wire can be used) from the plantar medial location of the heel spur excision, through the same small skin incision. This seems to increase the success of the surgery, and has the advantage of being parallel to the arch of the weightbearing calcaneus. Calcaneal fracture was a postop complication of the previous method of calcaneal decompression.
    After you have run out of all the biomechanical and physio methods, surgery may be a consideration.
  11. Very definite statement could be many things

    any papers that you know would be interested to have a read.
  12. Frederick George

    Frederick George Active Member

    Well Mike, if you compress the calcaneus and it causes pain, it really can't be "many things." (What "things?")
    That's the point of clinical diagnosis.
    But, a scan might help.

    I didn't read about this, it was hands on. If you are really interested, I'm sure you can find something.


  13. But, a scan might help. - Correct

    I didn't read about this, it was hands on If you are really interested - Beijing presented a study- Nice tone I go look then when someone presents a study usually it going to be in a journal - how silly of me for asking.
  14. RobinP

    RobinP Well-Known Member

    Forgive my ignorance here.

    If I compress the calcaneus(medial/lateral compression) and it hurts, it is bone marrow oedema of the calc?

  15. Bone marrow edema is more of a finding than a diagnosis. Instead of using the term "bone marrow edema" as a diagnosis, I believe that possibly we should be using the term "microfracture of plantar calcaneus" as a diagnosis. As Fred stated, MRI scanning has given us great insight into many metabolic and injury processes in bone that we have never been able to see before non-invasively, prior to MRI. Bone marrow edema is not uncommon on MRI scanning of patients who have plantar heel pain caused by traumatic falls where the individual lands forcefully on the calcaneus and also in long-standing proximal plantar fasciitis.

    Pain with side to side compression may or may not correlate positively with plantar calcaneal edema, but I do use this clinical test to determine the severity of the plantar calcaneal pain. Hopefully, some clinical research will occur in the not-too-distant future that will determine how sensitive and how specific the "side-to-side calcaneal compression test" is in determining "plantar calcaneal bone edema".
  16. Ian Harvey

    Ian Harvey Active Member

    Is the pain on compressing an oedematous calc specific to the point beneath the finger or thumb, and is it only at that point, or is it a more general pain within the calc?

  17. efuller

    efuller MVP

    I've always been skeptical of that procedure. What is the post op course of the procedure. A week or two of minimal weight bearing of the foot? Wouldn't that help the majority of foot pain?


  18. David Smith

    David Smith Well-Known Member

    Not knowing anything about bone marrow oedema I Googled and found that it is now commonly called bone marrow oedema syndrome (BMOS/BMES[U.S.). This was discussed in 2008 on PA here http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=10504. I also found that the finding is just an indication of some other pathology and not really a diagnosis in itself. There appears to be two general types of bone marrow oedema 1) hypervascularisation and 2) avascular necrosis, the former is self resolving indication of some other pathological condition in general ( the attached paper on metatarsal fractures first recommended by Kevin Kirby shows this principle) and the latter is of course a much more ominous and debilitating morbidity requiring medical intervention. (see attached paper on BMOS )

    Regards Dave
  19. Here is an excellent article on the pathomechanics of bone marrow edema in traumatic injuries to the knee from over 10 years ago that describes the bone trabecular injuries (microfractures of the trabeculae, is my guess) that are thought to result in the MRI finding of "marrow edema".

  20. Frederick George

    Frederick George Active Member

    Dear Robin

    Yep. Just make sure you aren't causing pain by pressing on skin lesions, nerve, tendon, etc.

    The calcaneus isn't that flexible, but by firmly pressing you increase the internal pressure just a little bit, causing pain. This is from the inflammation caused by the heel spur/plantar fasciitis, or Sever's.

    Saying "guess" or "may or may not" simply is another way of saying I don't know.

    By the way, I didn't say this is "plantar bone marrow oedema" or "microfractures of the trabeculae." When you squeeze the body of the calcaneus, the whole bone aches. A lot.

    Mike, I knew you could find something. Good to hear that the early knowledge hasn't been lost.

  21. RobinP

    RobinP Well-Known Member

    Some really good information here-this has turned into a really good thread with some good clinical applications.
    Thanks people
  22. manmantis

    manmantis Active Member

    I'll echo Robin's comments about the excellent information above. Thank you to everyone for your contributions thus far. I've learnt something new about bone marrow oedema which is excellent. :good:

    I had a look at the X-ray & U/S results today. Absolutely nothing to see on either. In fact given his history I am quite surprised how "normal" everything looks. No plantar fascia changes, no tibial nerve pathology, no sign of stress #...Just, normal. I can post these up if anyone wants a look, but I honestly don't think there's anything to see.

    I could send him for an MRI via his GP, given the comments on bone oedema above. At this stage however, several weeks after presentation of heel pain, wouldn't we expect to see some changes on X-ray?

    I've no experience with trigger points, so I'd probably need to discuss this with my physio colleagues, but surely any such issues would have reduced with the very frequent calf massages he's been having? As I said before, the sharp calcaneal pain has been the one constant, even when what I assumed were plantar fascia symptoms had been improving.

    I'm seeing him on Thursday, and will try & get some pictures/video if I have time.

    Thanks again.
  23. Frederick George

    Frederick George Active Member

    Dear Manmantis

    Does it hurt when you squeeze his heel, just like the test for Sever's?

  24. manmantis

    manmantis Active Member

    Hi Frederick,

    Yes, symptoms seem very similar to Severs. Sharp pain elicited by medial/lateral compression of the margins of the posterior tuberosity.


  25. So Bone marrow edema is a bit like a bakers cyst/popliteal cyst in that it is a sign and symptom of another diagnosis and may just indicate that the problem is long term unless direct landing trauma has been noted ?
  26. Frederick George

    Frederick George Active Member


    Yes, it's a result of inflammation in a closed area. Stretching the analogy a bit, perhaps more like a compartment syndrome, in that there is no discrete anatomical structure formed (cyst). Something that can become an entity in itself, and may need to be treated directly.
    Usually though, if associated with long standing plantar fasciitis, for example, if you have successful conservative treatment of the primary diagnosis (eg orthotics) the bone oedema will subside and become asymptomatic.

  27. Bone marrow edema is not a diagnosis any more than the plain film radiographic finding of subchondral sclerosis is a diagnosis. The subcortical edema may occur from excessive compression forces acting on the trabeculae possibly leading to microfracture of the trabeculae, and the edema may also possibly result from excessive tensile forces acting on the bone leading to excessive tensile damage to the subcortical trabeculae.

    In the future, with more research, I believe we will commonly appreciate that the pain from the condition we now call "proximal plantar fasciitis" is as much a bone compression injury, from the subcortical trabeculae of the plantar calcaneus being damaged by excessive magnitudes and loading rates of ground reaction forces acting over time on the plantar calcaneus, as much as it is from excessive tensile forces from the plantar fascia acting on these same damaged subcortical trabeculae of the plantar calcaneus.

    I tell patients that the MRI finding of bone marrow edema is somewhat like a "bone bruise due to a microfracture of bone", meaning there is more fluid deep within the bone in the area of bony injury which is occurring in response to the bone injury. This seems to communicate the nature of these injuries to the non-medically trained patient as well as anything else I have used as an explanation.

    Here I'm sitting at Sacramento International Airport waiting for my flight to Philadelphia and then on to Manchester with nothing better to do........hope Craig gets out of Melbourne before the volcano in Chile has its way with the airspace around Australia....


    Don't worry Craig, we'll drink all your beer for you if are a day late!
  28. nick_700

    nick_700 Active Member

    So Kevin what you are suggesting is an underlying stress reaction leading to microtrabecular fracture and the resultant bone marrow oedema.

    What then does everybody think about immobilisation osteopenia? The reason I bring this up is because somebody mentioned earlier that fenestration of the calcaneus may not be the answer, but possibly the post-operative immobilisation does the trick.

    The concept of immobilisation osteopenia has got me thinking. Naturally this concept is nothing new, however I was surprised at how early changes occur. Osteopenic changes can be visible on MRI as early as 3 days into beginning a non-weightbearing course. This was demonstrated to me by a radiologist last week in a series of MRI case reports.

    So...in the case of these microtrabecular fractures, could immobilisation predispose to further insufficiency fractures later on???

    I am also aware that I may be making a moot point here, as generally if a patient presents with a non-displaced fracture of an osseus structure I will typically immobilise them and they typically get better.

    Anyway, it is just a thought.

    Manmantis would you consider ordering an MRI for your patient? If the scan was positive for bone marrow oedema (due to an underlying microtrabecular fracture) would it change your management?


    Nick Ryan
  29. nick_700

    nick_700 Active Member

    PS enjoy Craig's beer :drinks
  30. Frederick George

    Frederick George Active Member

    Kevin, how do you know there is microfracture of the trabeculae?


  31. Frederick:

    I don't know for sure if the bone edema seen in traumatic injuries is always caused by microfracture of the trabeculae. However, it certainly seems that fracture of the trabeculae, either by abnormal compression, tension or shearing stresses is most logical cause of what we now call "bone edema" based on the available research and known microscopic anatomy, biomechanics and pathophysiology of bone in response to abnormal stresses.

    Here is an excellent book which includes an excellent discussion on the microphysiology of bone which I highly recommend by Neil Sharkey and coworkers:

    Martin RB, Burr DB, Sharkey NA: Skeletal Tissue Mechanics. Springer-Verlag, New York, 1998.
  32. Frederick George

    Frederick George Active Member

    Kevin, how do you know there is "microfracture of the trabeculae?"


  33. Frederick George

    Frederick George Active Member

    Kevin, even though this may seem theoretically logical to you, and keeping to the clinical point, I mostly see symptomatic bone marrow oedema where there is long standing heel spur/plantar fasciitis. These patients often have also developed compensatory achilles tendonitis, so they aren't doing a lot of heel contact.

    I think in these cases the inflammation, because that is what the bone marrow oedema illustrates, could be caused by the rupturing of the plantar fascia attachment, Sharpey's fibres etc.

    Certainly one could have traumatic internal fractures, akin to a stress fracture, that would also cause bone marrow oedema.

    I also think, for want of a better diagnosis (guessing is not better), bone marrow oedema is adequate when that's all we have. We certainly use "heel spur" and "hallux valgus" as diagnoses, symptomatic or not, and these are just xray findings.


  34. manmantis

    manmantis Active Member

    Apologies for not following this up.

    In answer to your question Nick, I discussed the options of MRI and indeed a bone scan with some Radiographer colleagues. We haven't had direct referral access to MRI as Podiatrists locally but I have negotiated such. The only problem is that the nearest scanner is a 2 hour drive away and MRI does not attract any Medicare rebate. So my patient/friend has a 2 hour drive & $250 to consider. A bone scan can be done locally, the question is would it tell me anything useful?

    Would either of these investigations change my treatment plan? Probably not, but it would be nice to see the "diagnosis" confirmed.

    My treatment thus far has focused on off-loading/cushioning the calcaneus. That line of treatment has been to date reasonably effective. I have advised him that if the pain continues then we really need to consider the use of a Cam-walker or similar to fully off-load his heel(s). He now gets good days, then does something high impact & it then hurts for a few days after. Lets call the scenario "managed discomfort", he's quite reluctant to go to the next level of therapy.

    Cheers for the advice so far.
  35. nick_700

    nick_700 Active Member

    Thanks for the follow up manmantis. I am in Melbourne and whilst MRI is more easily accessible, the prohibitive cost is indeed an issue (>$275). The poor specificity of a bone scan may let you down. It will tell you something is happening but not necessarily what that something is (i.e. tumour/fracture/infection etc...)

    Good luck, keep us posted :D
  36. and that's a good reason not to treat family and friends
  37. nick_700

    nick_700 Active Member

    Mike you are 100% correct


    Manmantis obviously lives in an area that has limited options for medical imaging, based on the fact the patient needs to drive 2 hours for an MRI. Therefore there may also be limited options for treatment by another podiatrist i.e. a semi-rural area. That situation is not unusual in various parts of Australia.

    Whilst treating family and friends can get tricky from a financial perspective (I've been burned before!), Manmantis' friend may not have another option. And also, how do you go about telling somebody "Yes I am a podiatrist, yes I could help you, but no I won't help you. Drive 2 hours to the closest major centre and seek help from one of my colleagues who I have no direct relationship to and may not have the same knowledge/skill set that I do"

    But you make a good point. Treating family and friends is way too hard and I cringe whenever I get a text/email asking for my clinic phone number :wacko:
  38. nick_700

    nick_700 Active Member

    And Mike I love your song of the week!
  39. On the other hand, when my mother-in-law, who I love dearly, asked me about her bunion and if I could fix it for her, I told her that I would have no problem doing the surgery to correct it for her. I couldn't bear it if someone else had done a poor job on her surgery, and she ended up with more pain after surgery than before surgery, when I knew I could do a good job on it for her. It all depends on what you and the relative feels comfortable with.

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