HEEL PAIN – “For the Record”

Report
41ST Annual Goldfarb Clinical Conference
Valley Forge Casino Resort
King of Prussia, PA
11-08-13
James A Marks, DPM, FACFAS, FAPWCA
Medical Director, The Wound & Skin Healing Center of
Washington Health System
Foot and Ankle Specialists / Washington Physicians Group
Employed by Washington Health System
& Washington Physicians Group
Speakers’ Bureau for Shire Regenerative
Medicine
Father of 4 ~ Luca’s Grandfather
“Well done is better than well said.”
~ Benjamin Franklin
James A. Marks DPM, FACFAS, FAPWCA
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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
Causes of Heel pain
How to self treat before calling a Podiatrist
Heel pain work-up
Discuss treatment
New treatments
Surgical options
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James A Marks, DPM, FACFAS, FAPWCA
James A Marks, DPM, FACFAS, FAPWCA
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James A Marks, DPM, FACFAS, FAPWCA
 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
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James A Marks, DPM, FACFAS, FAPWCA
 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.
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James A Marks, DPM, FACFAS, FAPWCA
Kelton Research 1,082 surveyed
James A Marks, DPM, FACFAS, FAPWCA
Plantar fasciitis/iosis
Plantar fibromatosis
Stress fracture
Nerve entrapment
Trauma
Calcaneal apophysitis
Tarsal tunnel syndrome
Calcaneal bone cysts / tumors
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James A Marks, DPM, FACFAS, FAPWCA
Mechanical
Neurological
Rheumatological
Traumatic
Infectious
Metabolic
Neoplastic
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James A Marks, DPM, FACFAS, FAPWCA
Mechanical
 primarily plantar fasciosis
Neurological
 primarily nerve entrapment
Rheumatological
 primarily seronegative arthritides
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James A Marks, DPM, FACFAS, FAPWCA
Plantar fasciitis
Heel Spur Syndrome
Inferior calcaneal bursitis
Heel bruise “Policeman’s Heel”
Stress Fracture
Fat pad pathology
Chronic compartment syndrome
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James A Marks, DPM, FACFAS, FAPWCA
 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
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James A Marks, DPM, FACFAS, FAPWCA
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*First described by
Woods, 1812
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
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James A. Marks DPM, FACFAS, FAPWCA
History
Physical
Imaging
Blood tests
For inflammatory arthritis
Nerve conduction studies
For nerve pathology
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James A Marks, DPM, FACFAS, FAPWCA
Location of pain?
Nature of pain?
Duration of pain?
When does the pain occur?
Age, physical make-up,
activities?
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James A Marks, DPM, FACFAS, FAPWCA
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?
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James A Marks, DPM, FACFAS, FAPWCA
Palpation
Range of motion
Functional testing
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James A Marks, DPM, FACFAS, FAPWCA
(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
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James A Marks, DPM, FACFAS, FAPWCA
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James A Marks, DPM, FACFAS, FAPWCA
Plain film X-rays
Generally the starting point
Bone scans
Increased bone turnover
Ultrasonography
Soft tissue problems
CT Scan
MRI
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Plain Films
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Tech Bone Scan
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James A Marks, DPM, FACFAS, FAPWCA
MRI: T1
MRI: T2 fat suppressed
sagittal image abnormal
signal in proximal plantar fascia and bone marrow edema
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James A Marks, DPM, FACFAS, FAPWCA
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James A. Marks DPM, FACFAS, FAPWCA
www.pennfoot.com
James A. Marks DPM, FACFAS, FAPWCA
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www.pennfoot.com
Avoid walking barefoot
Shoe modifications
Icing and rest
Stretching
Night or resting splint
Supplemental arch support
(OTC vs. custom orthotics)
Oral & Topical NSAIDS
Seek out Podiatrist if not
better in 4 weeks
 Throw out all “bad” shoes
 Too soft not always good
 Crocs good for certain feet
 Running shoe the best
 Avoid flat shoes
 Shoes to Avoid:
Flip flops!
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NSAIDs
Cortisone injection ???
Air-heel brace, heel cup, heel lifts
OTC Orthotics, etc.
 Patient education:
Elimination of barefoot walking
Activity alteration - RICE after activity
Stretching of plantar fascia & Achilles tendon
Proper shoe gear
Weight loss program & Lifestyle change
James A. Marks DPM, FACFAS, FAPWCA
Reappoint in 3 weeks
YOU ARE NOW 3-4 WEEKS PAIN LEVEL 5 OR 
Reassess exam and review testing results
 Patient education reinforcement
 Physical therapy
 Cortisone injection
NSAID adjustment (oral & topical)
Night splint
Proper shoe gear
Off-loading DME products
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James A. Marks DPM, FACFAS, FAPWCA
YOU ARE NOW 7-8 WEEKS PAIN LEVEL 5 OR :
Reassess exam and chief complaint
 Patient education reinforcement
Reassess effectiveness of PT
Cortisone injection ??
NSAID adjustment (oral & topical)
 Rx: Custom Molded Orthotics
Special testing: MRI, Bone scan, EMG/NCV
Reappoint in 6-8 weeks
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James A. Marks DPM, FACFAS, FAPWCA
YOU ARE NOW 3-6 MONTHS PAIN LEVEL 5 OR :
Reassess exam & chief complaint
Any additional testing needed?
 Patient education reinforcement
Cortisone injection ??
NSAID adjustment (oral & topical)
 Immobilization
 Surgical intervention Referral
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James A. Marks DPM, FACFAS, FAPWCA
Shockwave treatment
Platelet Rich Plasma Injection
Topaz (Coblation)
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James A Marks, DPM, FACFAS, FAPWCA
For more information…
Monday through Friday
8 am – 4:30 pm
Wilfred R. Cameron Wellness Center
208 Wellness Way, Bldg.1

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