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Neurogenic etiology of heel pain

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Asher, Mar 19, 2009.

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  1. Asher

    Asher Well-Known Member


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    Hi there,

    I have a patient with heel pain that hasn't responded to the usual first line treatments. His pain is reproduced the most when he inverts and plantarflexes his foot.

    I have been reading up on heel pain differential diagnosis and have come across Phalen's test. Apparently inversion and plantarflexion increases pressure within the porta pedis and therefore on the nerve. A positive Phalen's sign (numbness or pain) indicates nerve compression syndrome for the posterior tibial nerve or any of its branches.

    My main reason for posting is to get a gauge as to whether this inversion / plantarflexion manoeuvre causing heel pain is commonly encountered.

    Thanks
    Rebecca
     
  2. Ella Hurrell

    Ella Hurrell Active Member

    Re: Neurogenic eitiology of heel pain

    Hi Rebecca

    Please could you give a bit more info about this case....

    What 'first line' treatments have you tried already?
    Is the pain reproduced by inversion/plantarflexion neuro-type pain? ie. does he actually get numbness/pins and needles etc?
    Is the pain reproduced on active or passive inversion/plantarflexion?
    What makes you think it is nerve related, as opposed to a posterior tibial tendon issue for example?
     
  3. Asher

    Asher Well-Known Member

    Re: Neurogenic eitiology of heel pain

    Hi Ella,

    Tibialis posterior is strong with muscle testing.

    The patient reproduces his sharp shooting pain with active unresisted inversion and plantarflexion.

    Palpation just anterior to the plantar medial calcaneal tubercle elicits pain also.

    This 60 year old man has had heel pain for three years. He has a hallux rigidus so I'm limited with what I can do to facilitate the windlass mechanism but have tried temporary measures to reduce excessive pronation and arch flattening with no success. Calf stretches and night splints helped only a little. Cortisone injection (some time ago now) and NSAIDS have not helped.

    Without going into more detail, I just wondered about this Phalen's test (more commonly performed at the wrist) as I have not considered it before.

    Thanks for your interest.

    Rebecca
     
  4. Re: Neurogenic eitiology of heel pain

    Don't know much about Phalens test. Have you performed a Tinels test? Also check for trigger points in soleus as these can refer to this region.
    BTW, funky spelling of (a)etiology
     
  5. Admin2

    Admin2 Administrator Staff Member

  6. Asher

    Asher Well-Known Member

    Re: Neurogenic eitiology of heel pain

    Thanks Simon,

    Tinel's is negative. Soleus, quadratus plantae and abductor hallucis trigger points are negative also.

    I am only now getting xrays and diagnostic ultrasound done (this patient has been a bit hit and miss with keeping appointments over the course of his heel pain years but has promised to see this through now as its giving him so much trouble). I would like some advice on how specific to be on the ultrasound imaging referral form. As well as plantar fascia thickness at calcaneal attachment, can I ask for details specific to the posterior tibial nerve, the medial and lateral plantar nerves, the medial calcaneal nerve and the first branch of the lateral plantar nerve. Can the Ultrasonographer be expected to know these nerves, visualise them with ultrasound and follow their course to find any abnormalities. Or should I be asking for more general information like 'soft tissue masses medial and plantar calcaneus'.

    Thanks

    Rebecca
     
  7. Craig Payne

    Craig Payne Moderator

    Articles:
    7
    Last edited by a moderator: Mar 19, 2009
  8. Footsies

    Footsies Active Member

    i thought that plantarflaxion and eversion would put strain on the porta pedis?
    am i going crazy?
     
  9. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Chronic heel pain due to the entrapment of the first branch of the lateral plantar nerve: analysis of surgical treatment
    Journal European Journal of Orthopaedic Surgery & Traumatology
    Mohammad Mesmar, Zouhair Amarin , Nawaf Shatnawi and Khaldoon Bashaireh
     
  10. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    A 12-Year Long-Term Retrospective Analysis of the Use of Radiofrequency Nerve Ablation for the Treatment of Neurogenic Heel Pain.
    Cozzarelli J, Sollitto RJ, Thapar J, Caponigro J.
    Foot Ankle Spec. 2010 Sep 3. [Epub ahead of print]
     
  11. drsarbes

    drsarbes Well-Known Member

    Hi Asher:
    The difference between Plantar Fascia pain and Tarsal Tunnel/porta pedis pain can usually be appreciated via patient history, even before you actually examine him. Also, it is not unusual to find patients with both chronic plantar fasciitis as well as TT syndrome.

    When suspecting TT syndrome (or porta pedis compression, which frequently are one in the same) it is helpful to inject 1cc of plain decadron into the TT. If the patient gets relief (even short term ) or temporary increased symptoms (sometimes severe) then your Dx is fairly certain.

    Steve
     
  12. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Electrodiagnostic findings and surgical outcome in isolated first branch lateral plantar neuropathy: a case series with literature review.
    Ngo KT, Del Toro DR.
    Arch Phys Med Rehabil. 2010 Dec;91(12):1948-51.
     
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