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Persistent heel pain

Discussion in 'Biomechanics, Sports and Foot orthoses' started by David Smith, Feb 13, 2006.

  1. David Smith

    David Smith Well-Known Member


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    Dear All

    Have a lady patient of 57 with a persistent plantar heel pain left foot.
    B/feet valgus f/foot, stiff ankle dorsiflexion,(improved with mobilisation) very lateral STJ axis.
    She presented Oct 05 with a burning stabbing lateral heel pain l/foot.
    Taping improved condition, went to OTC orthoses and 8 weeks later on review heel pain resolved, Ultra sound scan revealed nothing remarkable except tendonosis of Ach tendon, considerably thickened areas tender to palpate. Refer to physio.
    1 month later l/foot heel pain plantar heel extremely tender like walking on a stone.
    L/foot Cut out 1st ray add heel lifts + 3dgs medial heel post and poron U pad in heel.
    X-Ray reveals no heel spur or any other remarkable findings.
    3 weeks later no improvement, probably worse.
    F-Scan with orthoses shows improved symmetry inter and intra foot. R/foot had very low push off pressure without orthoses but normal with them. Considerably less heel loading both in peak pressure and pressure impulse. Reduced hallux loading which had been very high but not correspondingly high at 1st mpj. However l/foot had early mid and f/foot loading, with orthoses, but not higher.
    Tried changing heel lifts and rear and f/foot posting but this does not significantly change timming of f/foot loading. Do you think extended f/foot loading could be increasing time of plantar fascia tension and causing trauma.
    (no signs on the scan or x ray) How can I decrease f/foot force impulse time.
    Any suggestions? Thanks Dave
     
  2. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    It sounds like mechanically she has a (equino-) cavo-varus foot type - so why have you posted your orthotic medially? This will only laterally displace the STJ axis further...Does the rearfoot look in MORE varus with your modifications?

    You post that she has "lateral, stabbing burning pain". This should make you think of neurological aetiologies. I would be thinking of entrapment of the 1st branch of the lateral plantar nerve or neuroma.

    Perhaps a diagnositic block might be good to help differentiate the aetiology?

    LL
     
  3. Call me old fashioned but I would stop playing with your toys and try and come up with a diagnosis first so you have an idea of what it is that you are trying to treat.
     
  4. David Smith

    David Smith Well-Known Member

    Dear LL

    Yes lateral neuropathy was my first thought and when first fitting orthoses I went for lateral f/foot posting only, which was fine for 2 months when she returned with plantar heel pain which is not neuropathic in type but more soft tissue trauma (plantar faciitis). Hence even though she has lateral STJ axis she still has early pronation so I c/o the first ray and medial posted the rearfoot to stabilise STJ reduce possibilty of FuncHL and improve saggital plane progression. According to the F scan this did improve saggital plane progression which, without orthoses, showed a block from heel lift to push off.
    The CoP progression was also very good and not deviating lateral (no orthoses) or medial (orthoses with lateral f/foot post).

    Simon, Yes I get your point and I only had the Fscan on demo but it did show up some relevant info which, I thought, might show up something to those who use Fscan and read this mail list. I did have 2 diagnosis the first was probably correct as the pain resolved but then the plantar pain started which I concluded was probably the result of the orthoses causing extra tension in the Plantar fascia. However I have not been able to resolve this and niether has the physio who suggested (I did not agree) that it may be a heel spur. We had X ray anyway which revealed Nowt. Ultra sound shows no soft tissue trauma, so I am a bit stuck.

    LL's suggestion of a block sounds OK for lateral pain but not for plantar pain or would this still be a good idea do you think?

    Cheers Dave
     
  5. Lawrence Bevan

    Lawrence Bevan Active Member

    Could be ur medially posted orthotic is leading to pf irritation. Classically this happens in the arch on the medial band but I have had it close to the insertion. Perhaps particulary in ur pt who from ur description has maybe a sl higher then average arch = higher orthotic = stiffer medial arch in orthotic.

    Maybe sl lower arch or grind accomodation for pf or I remember Howard Dananberg describing an orthotic modification involving cutting out a triangular section of the orthotic just in front of the medial side of RF post to create room for the fascia to move during propulsion.
     
  6. It appears that you are still treating her with an over-the-counter foot orthosis, Dave. You may want to try a custom foot orthosis first to see if the improved congruity to the plantar contours of the foot from a custom foot orthosis helps relieve her pain. Sometimes the simplest solutions are the best.
     
  7. David Smith

    David Smith Well-Known Member

    Hi Lawrence and Kevin

    Yes I think that may be it, the OTC device I used is fairly high and rigid, the ladies foot has a fairly average arch hieght in the medial arch. This would account for early Mid to f/foot loading and probable increased tension in the plantar fascia.Although I would have thought the 3mm poron U added to the heel cup might have alleviated this. Anyway I'll try a lower arch and goto a bespoke device if possible. Some times you can't see the wood for the trees (or toys) eh! I'll get back if this works.



    Thanks very much Dave
     
  8. Ian Linane

    Ian Linane Well-Known Member

    Hi Dave

    I wonder, have you considered whether you may actually have signifcantly improved the mechanics (keeping in mind Kevins comment) but that you are left with a referred pain from a trigger point? I have known this to be the situation sometimes. If so either needle it yourself or get a physio who does acupuncture to give it ago. It has worked for me a few times.

    Cheers
    Ian
     
  9. Craig Payne

    Craig Payne Moderator

    Articles:
    6
    This has come up in other threads. A foot orthoses may have helped the original problem, but an alteration in mechanics induced by the foot orthoses may have initiated a trigger point(s) in the intrinsic muscles. I have had dicussion with one physiotherapists who claims this is a common problem.
     
    Last edited by a moderator: Feb 15, 2006
  10. Compression stresses vs tension stresses as cause of plantar heel pain

    Since plantar heel pain is one of the most common symptoms I have treated in my 20+ years of practice, I would like to share my thoughts on this subject based on mechanical theory and my clinical experience in the treatment of thousands of patients with this condition.

    First of all, I strongly believe that plantar heel pain, what we typically call now "plantar fasciitis", is actually a whole host of separate pathologies that have multiple causations, but which produces nearly identical symptoms. In order to try to simplify the mechanics of plantar heel pain treatment, I have concluded that the vast majority of plantar heel pain is caused by either one or a combination of two basic mechanical factors:

    1. Excessive magnitudes of compression stress on the plantar structures of the calcaneus.

    2. Excessive magnitudes of tensile stress on the plantar structures of the calcaneus.


    Excessive compression stress may be caused by such factors as increased body mass, plantar fat pad atrophy, walking and/or standing for prolonged periods of time on hard surfaces, barefoot walking or running on hard surfaces, stepping on a hard irregular-shaped object on the plantar heel (e.g. stone bruise) or walking on an excessively hard surface inside the shoe (e.g. overly hard or improperly shaped foot orthosis).

    Excessive tensile stress may be caused by the plantar aponeurosis, flexor digitorum brevis or flexor digiti quinti exerting increased magnitudes of tensile force on their plantar origins on the calcaneus. Factors such as increased body mass, increased ankle joint dorsiflexion stiffness (i.e. equinus deformity), prolonged walking on inclined surfaces (e.g. walking on treadmill with belt inclined), prolonged walking in low heel height differential shoes, and prolonged barefoot walking may also cause increased magnitudes of tensile stress to occur on the plantar calcaneus.

    One little clinical test that I have been performing over the past decade that helps give me an idea as to which of these two pathological stresses may be the most important in causing the patient's plantar heel symptoms is to have the patient walk barefoot in the office on a standard flooring surface and ask them if the heel hurts more when the heel contacts the ground (i.e. at heel contact) or when the heel is leaving the ground (i.e. at heel off).

    Since the largest magnitudes of compression stress on the plantar calcaneus occur at heel contact, then if the patient gets the majority of pain at heel contact, then I consider that abnormal magnitudes of compression stresses are the cause of their plantar heel pain. Since the largest magnitudes of tension stress on the plantar calcaneus occur at heel off, then if the patient gets the majority of pain at heel off, then I consider that abnormal magnitudes of tension stresses are the cause of their plantar heel pain. Of course, there are many patients that have pain throughout the stance phase of gait so that it is likely a combination of compression and tension stresses on the plantar calcaneus which causes the patient's symptoms.

    This "plantar heel pain gait test" provides the clinician with another tool by which to optimize the specific design of their patient's mechanical treatment so that the most rapid resolution of the patient's symptoms will hopefully occur.
     
  11. Atlas

    Atlas Well-Known Member

    Great post Kevin, I agree entirely with your compressive v. tensile reasons of identical heel pain symptomology. Because low-dye taping helped initially, perhaps the tensile reasons may head my list; although low dye taping may limit the rearfoot motion and hence keep one region of the heel from contact.

    Lawrence, your questioning of the wisdom of medial posting, particularly as David referred to a very lateral STJ axis, has merit. I am not an expert in this field, but doesn't a medial post push a lateral axis more laterally??

    And David, in Kevin's experimental thread, I think he illustrated some limitations of pressure readings. Don't you think it is more important to judge interventions on the basis of patient symptom changes, rather than to fully base them on pressure reading changes??

    And another thing David, why refer to physio? Did the physio prescribe exercises or interventions that exacerbated the condition? Before this, it seemed that you had everything controlled well.
     
  12. John Spina

    John Spina Active Member

    It sounds like there is a baxter's neuroma over here.Entrapment of the1st plantar nerve is common.Why not try a PT block to see if relief can be obtained.(Archive Podiatry Today in 2005 for a fine article on heel pain and in particular there is good info on Baxter's neuroma.)
     
    Last edited by a moderator: Feb 15, 2006
  13. David Smith

    David Smith Well-Known Member

    Craig and Ian

    I'll take trigger points on board, would that be a distal soleous TRP do you think?

    Kevin
    Thanks for that good info, her pain is quite tender on palpation and heel strike, I'll take a second look.

    Atlas
    Medial heel post was only fitted after return of heel pain.

    If I was using Tekscan or simmilar regularly it would be as part of an overall analysis of gait just another tool in the tool box.

    Physio is better equiped to deal with Tendonosis than I and they are just down the hallway. Patient had one session of heat ultrasound and massage, no exercises she didn't return fot further appointments with physio for various reasons. But I did note that the heel became worse after physio. Maybe there was a reaction which set off a trigger point in the soleous.

    Thanks for all your replies, Dave
     
  14. Ian Linane

    Ian Linane Well-Known Member

    Hi Dave

    Hoping craig does not mind the following url:

    http://www.latrobe.edu.au/podiatry/myofasc/cover.html


    This gives a two shot option to trigger point areas,go for the one that seems closest to you need.

    Alternatively you could needle directly into the area of pain sometime called an Acupuncture Treatment Area (ATA) although not a trad' acupoint.

    Cheers
    Ian

    PS. don't mean to sound obvious. Have you looked at cross frictions to the area, normally a standard part of dealing with PF for me.
     
  15. Craig Payne

    Craig Payne Moderator

    Articles:
    6
    Proximal calf trigger point can cause heel pain (see the link Ian posted to LTU), but the one(s) I was refering to are those that can happen in the intrinsic muscles near insertion into calc.
     
  16. John Spina

    John Spina Active Member

    If tendonitis try this:Have your patient fill up a bottle with water.Freeze it.Then,have her roll the frozen bottle across her plantar fascia.It will stretch the fascia and have a soothing effect.
     
  17. David Smith

    David Smith Well-Known Member

    Ian

    Thanks for the link but I have that book already and use it as my main reference. Don't do acupuncture. Not sure about the effectiveness of Cross frictions don't use that technique very often.

    Regarding Craigs reply then perhaps cross frictions will work in this case.

    John, She is taped up and doing icing with a frozen tin 2 x daily, Hopefully.

    Cheers Again Dave
     
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