Heel pain pathways

[robertisaacs]

A colleague of mine (Sam actually) saw a patient today, referred from podiatric surgery.

He presented with a fairly classical plantar fascitis, Pain under the heel, worse 1st thing in the morning and after rest etc etc.

His care thus far had been to have three corticosteroid injections on three separate occasions from a Pod surgeon. Only after these had all failed was he being referred for orthotics / biomechanics. Nobody had so much as stuck a cushion under the heel!

My question therefore, is this. What would you consider to be an appropriate care pathway for Plantar fascitis.

IMHO treatment should be offered in tiers : -

Tier one

Heel cushions, lifestyle / footwear advice, Icing, home massage, NSAIDS (topical or oral), stretches

Tier two

Biomechanical assessment, orthotics, splints, strapping

Tier three
Injection therapies (Steroid, prolo, dry needling)

Tier Four
Surgery, PF release etc.

I would contend that one should think hard about escalating to a higher tier without exhausting the options on the lower.

I'd be interested to hear any opinions / other options.

What say you?

Regards
Robert

[blinda]

This does sound unusual. Why was the pt referred to a pod surgeon in the first place and by whom? This could be an example of the lack of understanding by other AHPs of what pods do perhaps? We really do need to promote what we do more effectively.

Anyway, yes I follow the same route with heel pain;


1) Medical history to rule out anything systemic/malingering, what exacerbates/improves symptoms, duration etc.
2) Physical assessment - dorsiflexing hallux and tracing to point of fascia inflammation.
3) I ALWAYS recommend stretching exercises, footwear advice, ICE anti-inflammatories and often issue heel cushions/cobra pads made from SCF as temporary device.
4) Follow up appt; biomech ass and orthoses, (not too keen on strapping, I find it time consuming and pts often can`t do it to themselves).
5) Then LAST RESORT; injection therapy/surgery, after further investigation e.g ultrasound, etc.

Cheers,
Bel

[TimVS]

As above. I would also add in treatment wise cross frictional massage, passive/active stretching of the posterior compartment. I also check for trigger points there as they can refer pain to the heel. I find that a basic low die strapping can be quite effective in the early stages, but 2 weeks max. Heel lifts can help too. I do wonder if the 'heel cushion' is maybe acting more as a heel lift than a cushion, relieving tension on the fascia, but we could be getting into semantics there!

Never yet had to go to stage 2, but that may change soon

Nice thread as I've got a right stubborn one at the moment which I may describe in more detail later.

[blinda]

I`ve had a few pts come to me for O/C tx after following the advice of their GP to "wear some lovely high heels" apparently this is the best tx for PF!!!!!!!

[davidsmith]

Robert

Tier 1 - Heel cushions, lifestyle / footwear advice, Icing, home massage, NSAIDS (topical or oral), stretches

From a purely clinical point of view and assuming that the problem has a biomechanical etiology, why not go straight to orthoses plus other complimetary interventions like icing, stretching, mobs etc.


Dave

[dtt]

Hi all

From a purely clinical point of view and assuming that the problem has a biomechanical etiology, why not go straight to orthoses plus other complimentary interventions like icing, stretching, mobs etc.

I agree with Dave on this, most of my P/F's come to me FOR orthotics and have tried various contraptions remedies,cushions all recommended by others BEFORE I get to see them so I don't see any point in repeating the same treatments.

I have had a couple that have come AFTER they have had corticosteroid injections but they are in the minority.

Only ever had to send one patient for surgery never had any feedback on how it turned out

That's my take on it

Cheers
D

[dtt]

Hi Freebie ( Tim)

Never yet had to go to stage 2,

Err do you not Rx orthotics after scanning them

Cheers
D

[robertisaacs]

From a purely clinical point of view and assuming that the problem has a biomechanical etiology, why not go straight to orthoses plus other complimetary interventions like icing, stretching, mobs etc.

Fair question.

It really depends on what form the biomechanical aetiology takes.

A quote from KK

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.

Regards
Robert

PS

I agree with Dave on this, most of my P/F's come to me FOR orthotics and have tried various contraptions remedies,cushions all recommended by others BEFORE I get to see them so I don't see any point in repeating the same treatments.

Agreed. One cushion is much like another. No need to repeat.

[dtt]

Hi Robert

One cushion is much like another.

I was referring to OTC paddings and cushions which as I'm sure most of the patients have tried ( whether correct or incorrect for the condition) that uncle Tom Cobbly and all have told the Pt is the best thing since sliced bread before they arrive with us.

From that point on after dispelling the myths the patient has learned from well meaning friends and surfing the internet, I can then begin treating using Footprint solutions simple orthotics ,or custom orthotics depending on my chosen pathway to resolution.

Hope that makes it clear.

Cheers
D