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Heel raise for enthesitis?

Discussion in 'Biomechanics, Sports and Foot orthoses' started by airamasor, Apr 28, 2010.

  1. airamasor

    airamasor Active Member

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    Hi everyone, I wonder if you could help.

    If a patient with psoriatic arthritis presents with enthesitis, would you give him a heel raise for the short term management?

    Also he's got bilateral genu varum, Tibial varum, ankle equinus and forefoot supinatus

    Is there any evidence for the use of heel raises?

  2. Craig Payne

    Craig Payne Moderator

    In my experience the use of mechanical therapies for the enthesitis from the seronegative spondyloarthropathies is about 100% failure.

    The enthesitis in these people is due to an inflammatory process from their disease, not from mechanical overload of the tissue, so why would mechanical therapies work?

    You can read a lot in some podiatric texts that you should use low dye strapping, orthotics etc for this (ie the same treatments that get used for the 'routine' plantar fasciitis), but I question the experience of the authors who make these claims.

    There is no evidence for or against using them (but there is something 'in press', but I not seen it yet).

    The only thing that seems to be effective is the use of the newer biologic agents that are used to treat the disease process.

    There was some discussion on this here:
    'Inflammatory' vs 'mechanical' plantar fasciitis

    Also keep in mind that just because they have a seronegative spondyoarthropathy, and present with pain in an entheses, that are are not immune to the 'routine' plantar fasciitis and the pain has nothing to do with the disease process.
    Last edited: Apr 29, 2010
  3. airamasor

    airamasor Active Member

    Thank you very much for your answer Craig.

    I was aware that biological treatment is the gold standard.
    Maybe I was trying to find a way, as podiatrist, to help this patient,
    but I wanted to base it on evidence.

    I take that rest and anti inflamatories (he's on DMARDs) will have to do
    at this stage. However, I will take into account differential diagnosis before
    treatment plan is agreed.

    Thank you again for the help

  4. David Smith

    David Smith Well-Known Member


    I would take the point of view that even tho heel raises might fail, they won't do any harm and should improve ankle function in gait. They are cheap and easy to stop using so why not try anyway. I always mobilise equinus ankle joints to see how they are after and take it from there. Even if the main pathology is inflammatory disease then excessive strain in those tissues won't exactly help the situation. Maybe the two interventions of DMARDs and strain reduction will work better than just one.

    Just my thoughts

    Cheers Dave
  5. Enthesitis is not a specific diagnosis since it does not describe the anatomical location of the inflammation.

    I definitely don't think heel raises would work for supraspinatus enthesitis.:bang:
  6. Harsh, but fair.;)

    I'm guessing from the original post by airamasor and subsequent postings that the tissue being discussed was the plantar fascia at it's calcaneal attachment. However, your definition of enthesitis creates a problem with that: "traumatic disease occurring at the point of attachment of skeletal muscles to bone, where recurring stress causes inflammation and often fibrosis and calcification". Since the plantar fascia is not a skeletal muscle, there can be no enthesitis of the plantar fascia by this definition.
  7. I've never hear plantar fasciitis called "enthesitis". The point is, with any of these clinical questions from members of Podiatry Arena where our clinical expertise is being requested, the rest of us shouldn't have to guess where the pain is located within the body of the patient. The person asking the question should make that very clear in the very first posting.

  8. When I went to school we were taught all about plantar "enthesopathy" whatever that is. The point you make is valid, the leg I pulled is equally valid... thanks for the alternative definition. Are you actually going to do some work in Italy, or just tour the sites?
  9. Mostly vacation for now. Lectures in Rome start next Friday AM. Just went through my lecture schedule a few minutes ago. Have 4 hours and 50 minutes of lecture on Friday and 5 hours 45 minutes of lecture on Saturday, all with simultaneous Italian-English translation. Should be fun!

    Here's the Spanish Steps from this AM....just about a 2 minute walk from our apartment. Awesome!

    Attached Files:

  10. Looks rubbish, a load of old steps...Doh.
  11. airamasor

    airamasor Active Member

    My apologies for not being specific enough. I am a third year student using the forum to learn and I sometimes get things wrong.

    The enthesitis is at the inserction of the Achilles tendon.

  12. Rosa:

    No worries. I was once a third year podiatry student....but that was 28 years ago. :morning:

    In most cases, pain and swelling at the insertion point of the Achilles tendon is caused by retrocalcaneal bursitis or retrocalcaneal spurring. Yes, heel lifts, or shoes with higher heel height differential, do help (due to decreased tensile force on the Achilles tendon during weightbearing activites) along with twice daily icing, gradual stretching of the gastrocnemius-soleus three times daily, non-steroidal antiinflammatory drugs (NSAIDS) and avoidance of barefoot walking. I have also found that suggesting patients wear open-heeled shoes, such as clogs, helps the pain greatly since it decreases any compression/shearing force between the shoe heel counter and the osseous and soft tissues of the posterior calcaneus.

    Hope this helps.

    By the way, welcome to Podiatry Arena.:welcome:
  13. Man, you should take more trips to Italy; it obviously chills you out big time seeing buildings that are more than a couple of hundred years old.;):drinks:empathy:
  14. We took the train from Rome to Venice this morning. Had a great vaporotto ride to our apartment on the quiet side of Venice. Then had a nice Italian dinner watching the sunset...a glass of wine...very nice!

    Attached Files:


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