#FirstAidForFeet

[footmanj-blog]

ASSESSING HEEL PAIN / PLANTAR FASCIITIS

Welcome to the first of a series of 3 articles about plantar fasciitis that I hope will help you understand the processes involved in achieving resolution of this often frustrating and sometimes debilitating foot condition. In this article we will look at assessment of the problem.

To keep terminology simple, I will use the label “heel pain” even though sometimes symptoms may vary from just pain and they may be located adjacent to the heel or further from it. So that brings us to one of the first important points we need to assess when looking at heel pain.

Where is the pain located?

A vague description won’t help us here as the foot is anatomically very complex with 26 bones, 33 joints, and more than a hundred muscles, tendons and ligaments. In just the sole of the foot where the plantarfascia is, there are 4 layers of muscles each with their own origins, insertions, functions and directions of pull. Directly under the heel bone itself (called the calcaneum) there is fascial tissue, fat pad, dermis, and epidermis.

Any of these tissues can get damaged so we need to look at the specific location of symptoms in order to ascertain which anatomical structure(s) may be involved. Is the pain on the inside or outside or back or underneath the heel? Is it on the bony part or the soft part of the heel? Is it nearer one of the ankle bones or further into the arch of the foot?

By pinpointing the symptom location(s) if possible, it gives us a great start to the assessment process. Remember that Podiatrists know foot anatomy intimately so can identify the structures affected.

Tell Jonathan Small, Lead Podiatrist, the story of your symptoms – right from the beginning

After introducing myself to a patient presenting with heel pain, and running through their medical history, I then move to learning about the problem that has brought them to see me, and their expectations of what they want from me. Often they are in a hurry to tell me about how it is at this moment in time (or at least within the past couple of days as its amazing how many say “its feeling easier now I’ve come to see you with it” – now if only I could bottle that magic and send it to all with foot pain!).

However HISTORY, HISTORY, HISTORY is so important for us to assess in order that we can help to fix the problem as quickly as possible and don’t waste time, energy, effort or money on chasing red herrings. So I want to know when the pain first started, during what activity, how did it progress, and how was it managed back then. The story then unfolds of the treatments tried, the limiting effects of the condition, the advice followed from others, and how the patient has ended up on my door as the person they hope can fix their feet. Once we’ve explored the past and established a historical timeline, we can then look at the present.

Describe your problem as of now

The next piece of the initial assessment process is about getting a comprehensive understanding of what the heel pain is like at present. What type of pain is it (such as burning, throbbing, shooting, stabbing, aching etc)? Does it move or even radiate? When does it feel worse/better? Is it present every day? All day? Which footwear helps/hinders the problem? There are many many more questions that we may ask depending on what any previous answers are, but once this process is finished, we will have a full picture of the symptoms in all their multi-coloured glory. This will be vital to record as we will reflect back on it at future appointments to ensure we are making progress with any treatment plan that the patient embarks upon.

Now let me take a look at you Through advances in medical science, there are many investigations that can be carried out to help achieve a correct diagnosis and establish an effective treatment plan. The first investigation should ideally involve some form of hands/eyes-on check of what is going on, otherwise important things can be easily missed. For instance, it is quite common for heel pain to be caused by a foreign body such as an embedded animal hair or a shard of broken glass, but because of the nature and location of the skin under the heel, it is hidden from the untrained eye. On many occasions I have seen patients who have a lot of information from “Dr. Google” for completely the wrong diagnosis, but we will cover this more in the next article.

You may have heard of the term ‘biomechanical assessment’. This is the process of looking at how your body functions with regard to movement such as walking / running. This can be as simple or as indepth as necessary, but it should always add to the pot of information regarding the presenting condition. It shouldn’t just be carried out for the sake of it. So using the example above, you should not need a biomechanical assessment for a foreign body causing pain in your heel, as long as that is the only cause of pain.

Therefore beware of people who advocate biomechanical assessments just because they can do them (to a greater or lesser extent) or because that is their only assessment tool. Saying that, a lot of heel pain (but not all) has a mechanical cause or contributing factor(s), and such assessment is likely to be more useful than an X-ray for example, as this only looks at one type of structure (bone) on the simplest level. Biomechanical assessments should involve 3 main stages, none of which will give a complete picture on their own, but when brought together they can really help to understand what is stopping resolution of plantarfasciitis for example. These 3 stages involve assessing the patient on the couch, assessing them standing, and assessing them when walking/running (and possibly other activities). During each activity your Podiatrist will be looking at how the joints, muscles, nerves etc are all functioning. They are not just looking to see if you have flat feet, high arches, pronation, supination, or any other of the simplistic descriptors of foot position / function frequently mentioned alongside heel pain.

Other useful (but generally not essential) assessments for heel pain are 3D gait analysis, force/pressure assessment, ultrasound investigation, MRI scans and blood tests. Knowing your Podiatrist is able to carry these assessments out, or have access to them via referral if necessary, would help to reassure that you are in good hands to get your heel pain sorted. However it is important to treat the patient, not the test results as they may be spurious.

So that’s the assessment stage covered

From all of these steps that make up assessment of heel pain (“plantar fasciitis”), we should now be able to make a diagnosis or at least have some differential diagnoses to help guide our treatments. In the next article, we will cover diagnosis in more detail.

The above indepth assessments of heel pain / plantarfasciitis are available from Jonathan Small, Lead Podiatrist at Health First Foot & Gait Clinic in Southam, Warwickshire, and Theorem Health & Wellness in Alcester, Warwickshire. Remember that Podiatrists are the Foot Specialists – #PodsHealHeels and #PodsFixFeet.

www.healthfirstsoutham.co.uk                

www.facebook.com/healthfirstsoutham

01926 811272   health1first@aol.com    

www.theoremhealth.co.uk/podiatry

Review on Google from Beverley Spicer:

“If you are suffering with Plantar Fasciitis Jonathan Small is your man. I was in agony for months and knew I needed a biometrics expert. Jonathan assessed my feet and provided a variety of insoles including one that he cast a mould of my foot to make. They were expensive, professional health care is not cheap, but years later I am still wearing and benefiting from my investment. My feet had hurt all of my life, but no longer! I am just back from a weekend walking in the Alps with happy feet! :)”

[footmanj-blog]

TREATING HEEL PAIN / PLANTAR FASCIITIS

Welcome to the last in a series of 3 articles about plantar fasciitis that I hope will help you understand the processes involved in achieving resolution of this often frustrating and sometimes debilitating foot condition. In this article we will look at treating the problem.

To keep terminology simple, I will use the label “heel pain” even though sometimes symptoms may vary from just pain and they may be located adjacent to the heel or further from it. For more information on the many possible diagnoses, please see the previous article in this series.

I reckon there are more treatment options for heel pain than the 57 varieties of Heinz, the world-famous manufacturer of baked beans. The reason that so many treatment options have developed over time, is because there is not one single guaranteed fix for the problem. In part this is due to people not being diagnosed correctly, and so embarking on inappropriate or ineffectual treatment regimes. Additionally, the following simplistic flowchart applies for every type of heel pain and every possible successful treatment:

So getting the right treatment at the right time is the only way to achieve resolution. As a result of this, there will be some success borne from luck (in the simple example above the odds of improvement are 25%). Note that as the condition improves the treatment may need to change, and the timing of that change is important too.  That then creates a much more complicated flowchart, and the odds of success from luck become much less, which is why an individualised treatment plan following indepth assessment and accurate diagnosis is essential to achieve complete resolution of symptoms.

The more treatment options available and the more the understanding of those, the better the chances of achieving symptom improvement / resolution. If the only tool you have in your tool box is a hammer, then all your problems begin to look like nails. The more tools (treatment options) you have available, the more the specific problem (diagnosis) can be addressed, and this is where good Podiatrists come in for treating heel pain. They will be able to offer some or all of the following at the right time for the right condition to fix foot problems including heel pain / plantarfasciitis:

Strapping therapy – We tend to use this for acute presentations of plantar fasciopathy and/or fat pad atrophy. Personally I tend to use a progressive strapping programme over a period of 3 weeks and this provides significant improvement quickly, whilst gradually increasing the stretch on the plantarfascia.

Load modification – By altering the load through the damaged tissue, symptomatic relief generally follows if done at the right time for the right condition. This may be through weight loss, activity modification, change in footwear, support socks, and the use of Gel Heel Cushions and/or functional foot orthoses (orthotics).

Orthotics – These are worthy of a separate mention as the term is often used alongside plantarfasciitis. To be clear, saying ‘wear orthotics for heel pain’, is like saying ‘take tablets for chest pain’. Without a diagnosis and understanding of what the orthotic or tablet needs to do, then how do we know what prescription is required. Orthotics should be prescribed in the same way that tablets are – materials properties, known interaction with the body, the dosage required for maximum effect, the length of the course of treatment, awareness of the side effects, and a review with the prescriber if symptoms persist for a possible change of prescription. On top of that there are cost implications that may influence the choice between the different types such as:

·         Over the counter (OTC) or off-the-shelf (OTS) orthoses also known as stock orthotics

·         Semi-bespoke orthoses which includes chairside insoles and heat-mouldable orthotics

·         Bespoke orthoses which are casted orthotics made specifically for the individual

Electrotherapy – In the past ultrasound therapy was a mainstay of treatment but it has been shown that results with it aren’t much better than placebo effect. Low level laser therapy is similar, but the electrotherapy that achieves the best results and is advocated by the National Institute of Clinical Excellence for the NHS is shockwave therapy of which there are different sorts and different prescriptions, just like with orthotics. The same therefore applies – machine properties, known interaction with the body, the dosage required for maximum effect, the length of the course of treatment, awareness of the side effects, and a review with the prescriber if symptoms persist for a possible change of prescription. On top of that there are cost implications that may influence the choice of treatment regime.

Mobilisations / Manipulations – These can help with soft tissue and joint movements to reduce strain on the plantarfascia. More and more podiatrists are making use of these techniques to help their patients.

Rehabilitation programmes – By stretching (possibly with help from a night-resting splint) and strengthening appropriate tissues with gradually increasing load, then the body’s cells repair and regenerate to ensure long-term resolution of symptoms. This is where patients have to do the work every day, and avoidance of it is the main reason for prescribed treatment plans not being as effective as they could be. In addition regular use of ice and elevation, or heat and massage at the right stages of healing can be useful.

Steroid injections – There are various injections that we use in specific situations to give relief from heel pain. They are not indicated nor effective in all cases, and when used as the only treatment, they rarely provide long-term resolution. Some injections are painful but pain-free techniques can be used by those trained to do them properly. Guided injections are thought to be more accurate in their placement of the steroid to reduce inflammation in a specific ‘hot-spot’ location.

Others - Some Podiatrists make use of acupuncture to help ease symptoms, and referral for platelet rich plasma injections or plantarfascia release surgery are also possible if required.

Review – This is an important part of a treatment programme to ensure progression to full resolution of symptoms and return to desired activities. A good review revisits, adjusts, plans, and supports the patient in the management of their heel pain.

By following all of the assessment, diagnosis, and treatment process for heel pain (“plantar fasciitis”), the condition should progress to complete resolution. In the same way that ‘Beanz meanz Heinz’ then ‘Plantarfasciitis means Podiatrists’. Nearly all of the above treatments are available from Jonathan Small, Lead Podiatrist at Health First Foot & Gait Clinic in Southam, Warwickshire, and Theorem Health & Wellness in Alcester, Warwickshire. Remember that Podiatrists are the Foot Specialists – #PodsHealHeels and #PodsFixFeet.

www.healthfirstsoutham.co.uk                

www.facebook.com/healthfirstsoutham

01926 811272   health1first@aol.com    

www.theoremhealth.co.uk/podiatry

 Review on Yell from JoW-254

“Plantar Fasciitis treatment - Specialist advice from a highly knowledgeable and skilled professional- bridging the gap between podiatry and physio for successful outcomes.”

[footmanj-blog]

DIAGNOSING HEEL PAIN / PLANTAR FASCIITIS

Welcome to the second in a series of 3 articles about plantar fasciitis that I hope will help you understand the processes involved in achieving resolution of this often frustrating and sometimes debilitating foot condition. In this article we will look at diagnosis of the problem.

To keep terminology simple, I will use the label “heel pain” even though sometimes symptoms may vary from just pain and they may be located adjacent to the heel or further from it. As we explore possible diagnoses in more depth, you will see that the common label of “plantar fasciitis” is just one of many possible labels, any of which could be more accurate and therefore lead to more appropriate interventions and better treatment outcomes.

If we break down the wording, then plantar fasciitis means inflammation of the fibrous tissue on the sole of the foot. The definition of inflammation is “a localised physical condition in which part of the body becomes reddened, swollen, hot, and often painful, especially as a reaction to injury or infection”. But this applies to only a small percentage of heel pain presentations. Indeed once you have looked through the list of possible diagnoses with below, you will see from their simplified explanations that true plantar fasciitis is probably not the correct diagnosis for many people who believe it is.

Heel pain caused by mechanical skeletal tissue stress

Acute Calcaneal Fracture – broken heel bone as a result of a single trauma such as landing on the heel from a height

Calcaneal Apophysitis – formerly known as “Sever’s disease” in which the heel growth plate becomes irritated in children

Calcaneal Stress Fracture – a partial break in the heel bone generally as a result of repeated trauma such as ligament pulling on weakened bone

Calcaneal Tumour – any tumour affecting the heel bone will lead to mechanical weakness of the structure

Systemic Arthridities – the effects of a generalised arthritic condition may affect the capacity of the heel bone to cope with mechanical stress

Heel pain caused by mechanical soft tissue stress

Plantar fasciopathy – acute or chronic disorder of any part of the plantarfascia that runs from the heel bone to the toes

Plantar fasciitis – inflammation of any part of the plantarfascia, generally acute (short duration) in its nature

Plantar fasciosis – irritation and thickening of any part of the plantarfascia, generally chronic (long-standing) in its nature

Achilles Tendinitis / Tendinopathy – the Achilles tendon connects the calf muscle to the heel bone and this can get inflamed or damaged

Heel Contusion – a bruise generally as a result of a single trauma such as landing on the heel from a height

Fat Pad Atrophy – underneath the heel there is a shock-absorbing fat pad that can waste away especially with age

Plantar Fascia Rupture – a tear for the plantar fascia itself

Posterior Tibial Tendinitis / Tendinopathy – the tendon of one of the foot stabilising muscles (posterior tibialis) runs close to the heel and this can get inflamed or damaged

Retrocalcaneal Bursitis – a deep fluid-filled sac, like a blister, but closer to bone and develop and become inflammed

Enthesitis / enthesopathy – an enthesis is where a ligament inserts into a bone and any of these can get inflamed or damaged, including the plantar calcaneal enthesis where the plantar fascia inserts into the heel bone

Metabolic disorders (ones that occur when the energy process in your body is disrupted)

Osteomalacia – “soft bones” often caused by lack of vitamin D can cause bone pain and muscle weakness

Osteoporosis and Paget’s disease – “weak bones” due to a disruption in the normal cycle of bone renewal can result in  bone pain and joint pain

Hyperparathyroidism – an increase in parathyroid hormone levels causes blood calcium levels to rise

Hypothyroidism – an underactive thyroid can cause several types of foot pain, including joint and muscle pain

Neurological disorders (ones associated with nerves)

Medial calcaneal nerve entrapment – one of several nerves that can be trapped around the ankle & heel area

Baxter’s nerve entrapment – compression of the first branch of the lateral plantar nerve (Baxter’s) may account for up to 20% of heel pain

Tarsal tunnel syndrome - also known as posterior tibial neuralgia, it is a compression neuropathy and in which the tibial nerve is compressed as it travels through the tarsal tunnel

S1 Radiculopathy – problems with nerve roots in the spine can manifest in the foot

Systemic diseases (ones that affect the whole body)

All of the following medical conditions can result in heel pain:

Tuberculosis, Ankylosing Spondylitis, Seronegative Arthropathies, Seropositive Arthropathies, Reiter’s Syndrome, Inflammatory bowel disease, Gout, Rheumatoid arthritis, Psoriatic Arthritis

Tumours

Tumours are swellings, generally without inflammation, caused by an abnormal growth of tissue, whether benign or malignant. There are many that can cause heel pain, including:

Metastatic tumour, Osteogenic sarcoma, Chondrosarcoma, Ewing’s sarcoma,  Unicameral bone cyst, Osteoid osteoma, Intraosseous lipoma, Aneurysmal bone cyst, Giant cell tumour

Whilst we are always mindful of malignancies in any aspect of medicine, we have to realise than common things are common, and rare things are rare. There is a phrase “think horses rather than zebras”, and only by carrying out a thorough assessment as discussed in the first article, can we be reassured that the diagnosis is likely to be one of the more common conditions. Once we have narrowed down our diagnoses, we can then look at appropriate treatment options, and this is discussed in the next article.

 Exploration of the above comprehensive diagnoses of heel pain / plantarfasciitis is available with Jonathan Small, Lead Podiatrist at Health First Foot & Gait Clinic in Southam, Warwickshire, and Theorem Health & Wellness in Alcester, Warwickshire. Remember that Podiatrists are the Foot Specialists – #PodsHealHeels and #PodsFixFeet.

www.healthfirstsoutham.co.uk                

www.facebook.com/healthfirstsoutham

01926 811272   health1first@aol.com    

www.theoremhealth.co.uk/podiatry

 Review on Facebook from Sue Ball:

“Have been suffering from plantar fasciitis for some time. After treatment and advice from the Foot and Gait Clinic my condition is manageable. Thank you I am now pain free.”

Review on Facebook from John Newbold:

“Very professional and friendly service - solved my foot problems where many others had failed -highly recomended.”