HEEL PAIN – “For the Record” A Community Presentation 41 ST Annual Goldfarb Clinical Conference Valley Forge Casino Resort King of Prussia, PA James A Marks, DPM, FACFAS, FAPWCA Medical Director, The Wound & Skin Healing Center of Washington Health System Foot and Ankle Specialists / Washington Physicians Group 11-08-13
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41 ST Annual Goldfarb Clinical Conference Valley Forge Casino Resort King of Prussia, PA James A Marks, DPM, FACFAS, FAPWCA James A Marks, DPM, FACFAS,
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HEEL PAIN – “For the Record”
A Community Presentation41ST Annual Goldfarb Clinical
ConferenceValley Forge Casino Resort
King of Prussia, PA
James A Marks, DPM, FACFAS, FAPWCA Medical Director, The Wound & Skin Healing Center of Washington Health SystemFoot and Ankle Specialists / Washington Physicians Group
11-08-13
PRESENTER DISCLOSURE
Employed by Washington Health System & Washington Physicians GroupSpeakers’ Bureau for Shire Regenerative MedicineFather of 4 ~ Luca’s Grandfather
“Well done is better than well said.” ~ Benjamin Franklin
James A. Marks DPM, FACFAS, FAPWCA
1984 PHOP RESIDENTS
TODAY’S OBJECTIVES
Summarize the most common causes and
treatment of plantar heel pain syndrome Provide a unique educational
experience for your public audience
Expand your current referral pathways within your community
www.pennfoot.com
James A. Marks DPM, FACFAS, FAPWCA
James A Marks, DPM Fellow, American College of Foot
and Ankle Surgeons
HEEL PAINAMERICA’S #1 FOOT
AILMENT
OBJECTIVES OF THIS LECTURE
Causes of Heel painHow to self treat before calling a PodiatristHeel pain work-upDiscuss treatment New treatmentsSurgical options
James A Marks, DPM, FACFAS, FAPWCA www.pennfoot.com
DOC, THIS IS WHERE IT HURTS!
James A Marks, DPM, FACFAS, FAPWCA
WHY?
James A Marks, DPM, FACFAS, FAPWCA www.pennfoot.com
YOU ARE NOT ALONE
HEEL PAIN 2 million Americans each year 90% of heel pain patients respond in 6 wks
to 6 mo Commonly shared risk factors: overly tight
calf muscle, poor shoe choices, weight gain, barefoot walking, or hard work surface.
3 times your body weight is transferred into your heel area with each step
James A Marks, DPM, FACFAS, FAPWCA
www.pennfoot.com
COMMON RISK FACTORS
Obesity or sudden weight gain Tight Achilles tendon Change in walking or running
habits Poor cushioning in shoes Change in walking or running
surface Job that requires prolonged
time standing/walking Excessive pronation of the foot
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Buchbinder, R. N Eng J Med. 2004; 350: 2159-66.
APMA FOOT AILMENTS SURVEY JANUARY 2009
James A Marks, DPM, FACFAS, FAPWCA www.pennfoot.com
APMA FOOT AILMENTS SURVEY JANUARY 2009
Kelton Research 1,082 surveyed James A Marks, DPM, FACFAS, FAPWCA
James A Marks, DPM, FACFAS, FAPWCAwww.pennfoot.com
The Truth about Heel Spurs
Calcaneal spurs are an adaptive response to vertical compression of the heel rather than longitudinal traction of the plantar fascia
Spurs do not grow in the plantar fascia
Degenerative changes due to stress reaction / micro-fractures
Kumai and Benjamin, J Rheumatol, 2002
James A Marks, DPM, FACFAS, FAPWCAwww.pennfoot.com
PLANTAR FASCIITIS* Pain on standing,
especially after periods of inactivity or sleep
Pain subsides, returns w activity
Pain related to footwear – can be worse in flat shoes w no support
Radiating pain to the arch & toes
In later stages, pain may persist/progress
throughout the day Pain varies in character:
dull aching, “bruised” feeling. Burning or tingling, numbness, or sharp pain, may indicate local nerve irritation
*First described by Woods, 1812
James A. Marks DPM, FACFAS, FAPWCA
www.pennfoot.com
MAKING the DIAGNOSIS
HistoryPhysicalImagingBlood tests
For inflammatory arthritisNerve conduction studies
For nerve pathology
www.pennfoot.com James A Marks, DPM, FACFAS, FAPWCA
HISTORY
Location of pain?Nature of pain?Duration of pain?When does the pain occur?Age, physical make-up, activities?
www.pennfoot.com James A Marks, DPM, FACFAS, FAPWCA
KNOWING PAIN
Location with what structures are in the area
Is the pain sharp or dull or burning?
Is the pain acute or chronic?Does it occur after activity?Related to a person’s weight or
activity?What relieves the pain?What has the patient already
tried?
www.pennfoot.com James A Marks, DPM, FACFAS, FAPWCA
PHYSICAL EXAM
PalpationRange of motionFunctional testing
www.pennfoot.com James A Marks, DPM, FACFAS, FAPWCA
MAXIMAL TENDERNESS
(1) plantar fasciitis
(2) entrapment of the
first branch of the
lateral plantar nerve
(3) heel pain syndrome
(4) fat pad disorders
James A. Marks DPM, FACFAS, FAPWCA
PALPATION
www.pennfoot.com James A Marks, DPM, FACFAS, FAPWCA
PALPATION
www.pennfoot.com James A Marks, DPM, FACFAS, FAPWCA
IMAGING
Plain film X-rays Generally the starting point
Bone scans Increased bone turnover
Ultrasonography Soft tissue problems
CT Scan MRI
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IMAGING
Plain Films
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IMAGING
Tech Bone Scan
www.pennfoot.com James A Marks, DPM, FACFAS, FAPWCA
IMAGING
MRI: T1 MRI: T2 fat suppressed sagittal image abnormal signal in proximal plantar fascia and bone marrow edema www.pennfoot.com James A Marks, DPM, FACFAS, FAPWCA