David Davidson, DPM presents the most common etiologies of plantar, posterior and pediatric heel pain. Dr Davidson reviews presenting features and provides an overview of initial conservative management, as well as tips for when the pain is recalcitrant. At the end of the presentation, Dr Davidson includes information about decubitus ulcerations encountered on the posterior heel.
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Release Date: 03/16/2018 Expiration Date: 12/31/2018
David Davidson, DPM
Center for Wound Care & Hyperbaric Medicine
Erie County Medical Center
Buffalo, New York
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Harold: Our next speaker is Dr. David Davidson who identified to me that he has actually been in practice longer that I am. So I acknowledge the wisdom that he has achieved in 43 or 44 years he has been teaching. He certainly has been in our profession as an educator. He is the chief of the Podiatric section, Department of Orthopedics in Kaleida Health System and that�s in Wound Care and Hyperbaric Medicine in New York. He is associated with the Buffalo School of Medicine, sports medicine and we�ve given him a topic on conservative management of heel pain, so please welcome Dr. Davidson.
Davidson: Thank you. Everybody here okay? So you�ve already seen this you know � I actually, as a clinical professor of Orthopedics in at the University of Buffalo. I work in the multidisciplinary center. There�s 27 orthopedic surgeons and athletic trainers etcetera so I treat a lot of very healthy people, including all most of the major athletic teams in the area including the Sabres and the Bills, in addition, a staff physician at our major trauma hospital and wound center. I treat the sickest of the sick, so I � I treat them all. Obviously I am - I am also in private practice in my third life. I know all you people would like to get off of, finish your residency and be super surgeons, but I think you really need to be more than that and I am sure you all know that. I�m on the speakers bureau for this [Indiscernible] [0:01:45] but I am not going to really talking about that, and Harold was very gracious in giving me 15 minutes to talk about everything I know about heel pain. And we will probably have some take � good take home points for you people. Obviously, the etiology of pain in the heel can be many; arthritic, biomechanical, neurological, traumatic, miscellaneous, systemic conditions, but the overwhelming cause is certainly, in my experience and experience of all our colleagues, is the overwhelming cause of heel pain is mechanical in nature. And we�ll obviously know about the anatomy. Patients come to our office all the time with all this internet searching, where I am not sure they find, and I am yet to find a picture of the plantar fascia that really is truly the picture of the plantar fascia, and I spend a lot of time talking to patients and explaining what � what the actual anatomy really is and the fascia begins at the joints, the MP joints and extends approximately and doesn�t end in the heel, but it�s really the intrinsic muscles superior to the fascia, the attaches to the heel. But the fascia continue so the aponeurosis of the fascia connects to the aponeurosis of the Achilles tendon so that�s kind of, like calf muscle, gastrocsoleus complex, Achilles tendon, plantar fascia is kind of all one structure. So you can call it anything you want, plantar fascia, it is plantar fasciosis, heels spur syndrome, but this is basically but clearly the number one cause of heel pain in my practice and in the practice of all of our colleagues.
So the history is very typical, the text book history you see almost all the time. It hurts when I get up, it hurts after rest. Etiology more often than not is too much too soon, changing shoes, increased weight gain is almost never a cause and that should be dropped from this. There are micro tears of the plantar fascia insertion which is why we, most of the time call it fasciosis. You will develop pain directly on palpation of the medial tubercle in that area, with or without noticeable swelling, with or without heel spur. But we all know that it is not the spur that�s causing pain, so why do we have the spur there at all, in cases of people with chronic fasciitis? Somebody, tell me why?. Why do you see a spur, what � what causes that? This is really a very basic question, you guys were sleeping in class, come on, anybody? What causes that extra heel, that extra calcification that you see on an x-ray.
Davidson: Traction of what? What you are seeing is, what happens is, those intrinsic muscles are pointed at the attachment, you get a little subperiosteal bleeding that calcifies when you doing fasciitis heel spur. But we know it is not the spur that�s causing the pain, so why do we bother to take an x-ray? Why take an x-ray of these people? Because it gives me a good idea of what kind of a patient we are dealing with. How long this patient is really had this problem. He may have only had pain for three or four weeks but if they have a large spur, we know that this been a problem, that has been going on for a long time. And as I said, most common cause clearly is the stress of that intrinsic muscle in plantar fascia and we will talk about that infamous or famous windlass mechanism which we are not going to talk about, because it only give 15 � they have only given 15 minutes. So typical symptoms, isolated plantar heel pain, pain after rest, improving with weightbearing, worse in the morning or after prolonged rest and this is � this is in the text book but in real life its not always the text book so there can be variations of this.
So what are our options? The truth is that statistically 95 percent of the people with plantar fasciitis get better with conservative treatment. So I know I am talking to a bunch of surgeons, but last resort, the very small percentage of people really require surgery. Stretching � stretching � stretching. This is a flexibility thing. Plantar fasciitis is basically an inflexibility problem, so stretching is a fine initial treatment. Night splints, sometimes I am not a real fan of night splints, because they are cumbersome and difficult to sleep in. Avoid going bare foot. Sometimes oral inflammatories, sometimes certain paddings and strappings, the famous low dye strap with longitudinal large padding will help. Occasionally, corticosteroids injections and I am not a real fan of steroid injections, certainly I am not a fan of multiple injections. If it�s an extremely painful and that pain is a trigger point where there is a lot of pain, I will give an injection, I will almost never give the second. I certainly won�t give the second if the first one didn�t work. weight loss is probably not an issue because there's this many 97 pounds weaklings that have a plantar fasciitis type heel as that of a 350-pound athletes. Over the kind of inserts, maybe �.
You know, in an adult, my philosophy is not to change the person�s biomechanics, because the body compensates for abnormal biomechanics and if you are going to change the mechanics even with the, over-the-counter insert, you may set up some other problems, so initially when I am treating heel plantar fasciitis problems, stretching, an occasional injection, occasionally an antiinflammatories, always stretching. And there's a whole plethora of different stretching exercises that which you can do. So, what happens if they come back in two weeks and they don�t get any kind of response at all? As I told you, if the first injection didn�t work, why would I repeat that? So I am not going to do that. Very often, I will send that person to a sports physical therapist who is very familiar with stretching for gastric soleus equinus, because most, some people can�t just do it themselves.
Prescription orthotics: Again, if the over-the- counter inserts help a little bit and that�s enough prescription orthotics. Immobilization is a silly thing and I don�t do that. Some of our colleagues do. My problem with that is if you put somebody in a cast or a cam walker and immobilize them, their pain is going to go away but the minute they get out of the immobile - immobilizer, their pain is going to come back again so that doesn�t make any sense. So 95 percent of the people get better with conservative therapy, 5 percent don�t, so maybe it is surgery, minimum of six months of conservative care in my office, before I even entertain the thought of surgical intervention. Open fasciotomy endoscopic fasciotomy, heel spur resection, as far as I am concerned, in this thing day and age doesn�t belong in this list anymore. Extracorporeal shock wave therapy and topaz. People familiar with that, the last two? We will talk about that very briefly. Can�t go away just talking about the bottom of the heel, but the back of the heel insertional or non insertional Achilles tendinopathies with or without a Haglund�s deformity, and of course a calcaneal apophysitis in young kids.
Most common symptoms of the posterior heel pain is generally there are insidious aggravated by increased activity and certainly irritated by shoe pressure. So the initial treatment of posterior heel pain is reduction of that pressure, reduction of that tensile stress which is stretching � stretching � stretching. Frequently non steroidal anti inflammatories will be of help and there's a whole plethora of physical therapy modalities that can be used. For resistant, really resistant, very acute, yes you can immobilize them, over-the-counter inserts or custom orthotics, other physical therapy modalities, and when all else fails - when all else fails then you can talk about surgery.
Surgery -We resect the prominent bone. It�s a really new good technique out now, where you can even, get to that bone without detaching the Achilles, many times you � you like, can do a T incision and we have some neat stuff that will suture that tendon back to the bone.
Tendon debridement, shock wave therapy, topaz, osteotomy, Achilles tendonitis etcetera. And then of course calcaneal apophysitis. I am kind of skip through here, but here is some of the stuff that�s reasonably new in the last five years or so, and I am not really going to talk too much about any of those stuff because I don�t have any time.
Topaz in my neck of the woods is not covered by insurance. But yet we do it as an ancillary technique to something else. And it�s basically radio frequency energy and saline and maybe it�s just the needling that does it. Because trigger point needling therapy seems to work quite well and there are some studies that show that it works well.
We have been playing especially in my sports practice at university, with platelets with plasma, this is been used and I have used in my wound care center very successfully, even more successful with some of the sports injuries. And its basically just spinning, you know that platelets are filled with lots of different growth factors, and taking the patient�s own blood, centrifuging it and putting and combining it with an [Indiscernible] [0:11:21] and injecting it into the area of most increased pain, works really well. But in all treatments, heel pain, any other kind of pain, evidence-based medicine, the truth is that most of us in this country do not practice
evidence-based medicine. Somebody will come into your office with a wound product or an injectable and say this is new and this is great, the first question that will come out of your mouth is, what�s the level one based evidence? What level of evidence do you have with this � that this works. In this level of [Indiscernible] [0:11:57] is extremely important in your practice. And the truth is that there is no level A evidence in heel plain. There�s plenty of level Bs, so we are not � we are not doing enough writing and enough research, so we really need to go through that, we need to work on this, all of us need to do this.
Additional cause of heel pain: Neurologic, arthritic, traumatic, the take home point in all this is not all heel pain is plantar fasciitis. So, you need to take a good history and physical. You need to do the appropriate testing and you need to listen to your patients. That is sure not good about the arthritis, I skipped through the tarsal tunnel, nerve entrapments slides, psoriatic arthritis, writers� disease, rheumatoid, fibromyalgia, these are all systemic problems that will cause unilateral or bilateral heel pain.
I love this last speaker Ryan, I pulled this off of Ryan�s face book page before he took it away. Because obviously trauma is going to cause heel pain, this is one of my favorite pictures, Ryan thanks for this, and I told you I would mention your name with it. And I can�t leave, my wound experience, I got to put this when we talk about heel pain.
I need to talk about heel ulcers jut for two seconds, because there's very little fat on the back � there is no fat on the back of the heel, minimal on the very posterior portion of the heel, so if you have an immobile patient with poor circulation or systemic issues such as anything that impairs the arterial inflow, there is a problem, there could be a potential problem, and this is the kind of the foot that I see in the hospital bed, every hospital bed that I might step in. This is the hospital�s way of offloading somebody�s heel. There�s lots of choices to offload heels, I just needed to put this in, I want you to stop at this booth in the exhibit hall. When you stop at all of them, because this is, this heel rest is a very new product and it�s just been out for a few months and it�s washable, antibacterial, it�s really a good product to take the pressure of the heel, typical ischemic heel such as this.
When we talk about heel wounds, it�s not what you put on the wound, it�s what you take off, that�s a course that talks about debridement, but it really talks about pressure also. Again the one take-home point that I have and I am going to echo Ryan and what Harold said that earlier that you know, I just gave you 42 text books in 15 minutes, the take home-point here. If a patient comes to you in your office and says the bottom of my heel hurts, don�t assume it is plantar fasciitis. It�s about 87 different things it could be, listen to the patients, take a good history, and do a good examination and you will see lots of different things, different causes of heel pain other than the mechanical, but clearly mechanical is the number one.