Heel Spur with Associated Plantar Fasciitis open[1]

Heel Spur with Associated Plantar Fasciitis: 

Heel Spur with Associated Plantar Fasciitis Christy Kappes Deborah Mazanek Jeff Smith Thomas Watson

Anatomy/ Biomechanics Review: 

Anatomy/ Biomechanics Review Plantar Fascia Attaches from calcaneal tuberosity to the proximal phalanxes covering the flexor digitorum brevis . Functions as shock-absorber and arch support Windlass Mechanism During toe-off in gait plantar fascia tightens, raising the arch into a closed-pack position. The rigidity tractions plantar fascia

Anatomy/Biomechanics cont.: 

Anatomy/Biomechanics cont. Hyperpronation and abnormal elongation of plantar fascia Extreme subtalar joint pronation produces greater tensile forces on plantar fascia. Tight gastrocs cause abnormal elongation of plantar fascia at toe-off of gait Arch Depression Flat-footed individuals are predisposed to excessive pronation Osteophytes Increased or abnormal loading to the calcaneus where the plantar fascia attaches triggers bone remodeling

Diagnostic Imaging: 

Diagnostic Imaging Plain Film Radiograph Bone Density increased at sub-calcaneal Increased osteoblastic activity within soft tissues. MRI Plantar Fasciitis and associated Soft Tissues Diagnostic Imaging

Imaging: 

Imaging MRI T1(above)/ T2(below) Alignment- Normal Bone Density- Increased bone density at sub-calcaneal region. Cartilage Space- Normal Soft Tissue- Increased calcification of plantar fascia and thickening of plantar aponeurosis.

Etiology: 

Etiology History of Plantar Fasciitis Repeated Trauma To Calcaneal Tuberosity Biomechanical Disfunction Hyperpronation/ Depressed Arch Improper Shoe Wear Ie. High Heels.

Prevelance: 

Prevelance Plantar Fasciitis Most common foot condition. Effects approx 2 million Americans Heel Spur 50% of patients that suffer from plantar fasciitis have a heel spur. 15-20% of patients without plantar fasciitis have heel spurs.

S&S: 

S&S Pain with: Weight bearing. Gait on even and uneven surfaces. Tenderness on plantar-medial aspect of calcaneous. Palpable calcium deposit on calcaneal tuberosity. Possible morning pain.

Diagnosis & Prognosis: 

Diagnosis & Prognosis Diagnosis Based on patient complaint, presentation of symptoms, and functional limitations. Confirmed with diagnostic imaging. Prognosis Based on treatment choice and severity of condition. Conservative treatments can take approximately up to 1-3 months with less risk to the patient. Aggressive treatments can shorten rehab time but at greater risk to patient.

Treatments: 

Treatments Electrocorporal Shock Wave Therapy (ESWT) Newer treatment option available. Reduce painful symptoms and fragments of calcium deposits.

Treatments: 

Treatments Iontophoresis Transdermal delivery of medication using electrical current (DC) Dexamethasone: corticosteriod anti-inflammatory Acetic Acid 5%: nonsteroidal medication to promote calcium reabsorption.

Treatments: 

Treatments Surgery Transverse plantar approach. Plantar fascia resection and partial resection. Arthroscopic Approach. Physical Therapy STM, Therapeutic exercises, stretching, modalities, joint mobilization Orthotics Heel Wedge Arch support Heel pad

Questions: 

Questions If treatments are unsuccessful, what other medical sources would you consider referring out to? What other soft tissue structures could be involved in the presence of a heel spur? What imaging modality would you use to confirm suspicions? If symptoms resolve, which imaging modality would you choose to confirm the re-absorption of the heel spur?

References: 

References Cornwall MW, Mcpoil TG. Plantar Fasciitis: Etiology and Treatment. J Orthop Sports Phys Ther . 1999;20(12):756-760. Gilroy A, MacPherson B, Ross L. Atlas of Anatomy . Thieme Medical Publishers Inc. 2008. Kosmahl EM, Kosmahl HE. Painful Plantar Heel, Plantar Fasciitis, and Calcaneal spur: Etiology and Treatment. J Orthop Sports Phys Ther . 1987;9(1):17-24. Cosentino R, Falsetti P, Manca S, et al. Efficacy of Extracorporeal Shock Wave Treatment in Calcaneal Enthesophytosis . Ann Rheum Dis . 2001;60:1064-1067. Anderson C, Morris R, Boeh S, et al. Effects of Iontophoresis Current Magnitude and Duration on Dexamethasone Deposition and Localized Drug Retention. Phys Ther . 2003; 83:161-170. Osborne HR, Allison GT. Treatment of Plantar Fasciitis by LowDye Taping and Iontophoresis : Short Term Results of a Doule Blinded, Randomised , Placebo Controlled Clinical Trial of Dexamethasone and Acetic Acid. Br J Sports Med. 2006;40:545-549 . Drake M, Bittenbender C, Boyles R. The Short-Term Effects of Treating Plantar Fasciitis With a Temporary Custom Foot Orthosis and Stretching. J Orthop Sports Phys Ther . 2011;41(4):221-231. Donatelli RA. Abnormal Biomechanics of the Foot and Ankle. J Orthop Sports Phys Ther . 1987;9(1):11-16. Japour CJ, Vohra R, Vohra PK, et al. Management of Heel Pain Syndrome with Acetic Acid Iontophoresis . JAPMA . 1999; 89(5):251-257. Bergmann JN. History and Mechanical Control of Heel Spur Pain. Clin Podiatr Med Surg. 1990;7(2):243-59. Costa IA, Dyson A. The Integration of Acetic Acid Iontophoresis , Orthotic Therapy and Physical Rehabilitation for Chronic Plantar Fasciitis: a Case Study. J Can Chiropr Assoc. 2007;51(3):166-174. Self T, Kunz R, Young G. Transverse Plantar Incision for Heel Spur Surgery: Four-year Follow-Up survey of 35 patients. Japma . 1993;83 (5): 259-262. Gibson W., Long W. Ultrasound of the plantar apenourosis (fascia). Skeletal Radiology. 1999;28:21-26.

References: 

References Images From http://www.digiport.co.uk/physio/heelspur.html http://www.jacksonfootdoctor.com/heel_spur.htm http://www.heelpainhq.com/heel-spurs/ http://www.flickr.com/photos/northcoastfootcare/4058174627/ http://www.vancouverorthotics.ca/Heel-Spurs-insoles-Good-Feet-Vancouver http://www.teamcrossworld.com/running/2010/curing-plantar-fasciitis/ http://faoj.org/2009/12/01/plantar-fibromatosis-a-case-report/ http://www.heel-that-pain.com/heel_spur/heel_spur_treatment.php