Value of radiographs in the initial evaluation of nontraumatic adult heel pain

Common Painful Foot and Ankle Conditions: A Review

Importance

Morton neuroma, plantar fasciitis, and Achilles tendinopathy are foot and ankle conditions that are associated with pain and disability, but they can respond to nonoperative treatment.

Observations

Morton neuroma, consisting of interdigital neuronal thickening and fibrosis, is characterized by burning pain in the ball of the foot and numbness or burning pain that may radiate to the affected toes (commonly the third and fourth toes). First-line nonoperative therapy consists of reducing activities that cause pain, orthotics, and interdigital corticosteroid injection; however, approximately 30% of patients may not respond to conservative treatment. Plantar fasciitis accounts for more than 1 million patient visits per year in the US and typically presents with plantar heel pain. Fifteen years after diagnosis, approximately 44% of patients continue to have pain. First-line nonoperative therapy includes stretching of the plantar fascia and foot orthotics, followed by extracorporeal shockwave therapy, corticosteroid injection, or platelet-rich plasma injection. Midportion Achilles tendinopathy presents with pain approximately 2 to 6 cm proximal to the Achilles insertion on the heel. The primary nonoperative treatment involves eccentric strengthening exercises, but extracorporeal shockwave therapy may be used.

Conclusions and Relevance

Morton neuroma, plantar fasciitis, and Achilles tendinopathy are painful foot and ankle conditions. First-line therapies are activity restriction, orthotics, and corticosteroid injection for Morton neuroma; stretching and foot orthotics for plantar fasciitis; and eccentric strengthening exercises for Achilles tendinopathy.

Sonographic and clinical effects of manual physical therapy for plantar fasciitis: randomized prospective controlled trial

OBJECTIVE

This study aimed to evaluate the efficacy of manual physiotherapy on clinical outcomes, morphology of plantar fascia (PF), thicknesses of calcaneal fat pad (CFP) and Kager's fat pad (KFP) with ultrasound imaging in plantar fasciitis (PFS) patients. Also, to evaluate the PF thickness, pain and foot functional outcomes among PFS phases.

METHODS

A randomized controlled trial was conducted on 122 subjects divided into three groups: group A (40 patients with PFS) underwent manual physiotherapy, group B (42 patients with PFS) without any intervention and group C (40 healthy subjects) were matched by age, gender and BMI with each patient in group A and B. The following outcomes were evaluated at baseline and one-month of follow-ups: morphology of PF and thicknesses of CFP and KFP, pain, foot functional limitation.

RESULTS

PF thickness was significantly thickened in group A and B compared to group C (P < 0.001). A significant decrease in incidence of PF echogenicity and CFP thickness were found in group A and B compared to group C. Moreover, significant improvement was observed in PF thickness (P < 0.001), PF echogenicity (P < 0.001) and CFP thickness (P = 0.002) in group A at one-month after the treatment. Furthermore, pain intensity and foot functional limitation was significantly improved within group A after receiving the treatment. Significant improvement was noted in PF thickness, pain intensity and foot functional limitation among patients with acute phase.

CONCLUSION

The manual physiotherapy is effective in treatment of PF thickening, hypoechogenicity, pain intensity and activity limitations, particularly in patients associated with acute PFS.

[Comparison between extracorporeal shockwave therapy and radial pressure wave therapy in plantar fasciitis]

OBJECTIVE

Plantar fasciitis is a common cause of heel pain. The aetiology of this condition remains unclear. Patients typically have pain upon palpation of the medial plantar calcaneal region. Extracorporeal shockwave therapy has shown favourable outcomes in various studies. The aim of this study was to compare the effect of focused extracorporeal shockwave therapy with radial pressure wave therapy.

PATIENTS AND METHODS

Seventy-nine non-randomised patients diagnosed with plantar fasciitis were included between January 2017 and June 2018. Patients from the Arnau de Vilanova Hospital in Valencia were treated with focused extracorporeal shockwave therapy, and patients from Llíria Hospital with radial pressure wave therapy. Measured outcome variables were: visual analog scale; ultrasonographic measurement of plantar fascia thickness; self-reported foot-specific pain and disability using the Foot Function Index; self-reported health-related quality of life using the Euroqol-5D; self-reported pain and limitations of activity using the Roles & Maudsley Scale.

RESULTS

At inclusion, the 2groups showed no significant differences in demographic or clinical characteristics. Three months after treatment completion, both groups showed improvement in all outcome variables, without statistically significant differences between the 2groups. No adverse effects or complications were observed.

CONCLUSIONS

Both extracorporeal shockwave therapy and radial pressure wave therapy are effective treatments for plantar fasciitis.

Plantar Fasciitis in Diabetic Foot Patients: Risk Factors, Pathophysiology, Diagnosis, and Management

Plantar fasciitis (PF) is a common degenerative disorder and a frequent cause of heel pain, mostly affecting patients in their fourth and fifth decades. Diabetic patients are particularly at risk due to the presence of common risks and co-morbidities such as obesity or a sedentary lifestyle. The diagnosis of PF is mainly clinical. Imaging is not recommended for the initial approach. The initial management is conservative and should include physiotherapy, off-loading, stretching exercises, and nonsteroidal anti-inflammatory drugs. Glucocorticoid injections or surgery is an option at a later stage in recalcitrant cases. The overall management of PF does not differ between patients with diabetic foot problems and non-diabetic patients, although the details can differ. This narrative review summarizes the state of the art in terms of the risk factors, pathophysiology, diagnosis, assessment, and management of PF in diabetic patients.

Evaluation and Treatment of Chronic Plantar Fasciitis

Plantar fasciitis is the most common cause of chronic heel pain in adults, affecting both young active patients and older sedentary individuals. It results from repetitive stress to the plantar fascia at its origin on the medial tubercle of the calcaneus and is often associated with gastrocnemius tightness. The diagnosis can be made clinically with a focused history and physical examination; imaging is reserved for atypical presentations and those that do not respond to initial treatment. The most common presenting symptom is aching plantar heel pain, which is worst with first step in the morning or after periods of rest. Diagnosis is confirmed with point tenderness at the origin of the plantar fascia on the medial tubercle of the calcaneus. Initial treatment consists of activity modification, anti-inflammatory medication, gastrocnemius and plantar fascia stretching, and an in-shoe orthosis that lifts and cushions the heel. These nonoperative treatments lead to complete resolution of pain in 90% of patients but can take 3-6 months. Patients who remain symptomatic despite a 6-month trial of nonoperative therapy may be considered for minimally invasive treatment or surgery. Platelet-rich plasma injections and therapeutic ultrasound are among a number of minimally invasive treatments that stimulate the body's healing response. Corticosteroid injections temporarily relieve pain, but may increase the risk of plantar fascia rupture and fat pad atrophy. Botulinum toxin injections relax the calf muscles, which decreases the stress in the plantar fascia. Operative treatments include gastrocnemius recession and medial head of gastrocnemius release, which decrease the stress on the plantar fascia and partial planter fasciotomy, which stimulates a healing response.

LEVEL OF EVIDENCE

Level V, expert opinion.

Pain on the Plantar Surface of the Foot

BACKGROUND

Plantar fasciitis (PF) is characterized by pain on weight-bearing in the medial plantar area of the heel, metatarsalgia (MTG) by pain on the plantar surface of the forefoot radiating into the toes. Reliable figures on lifetime prevalence in Germany are lacking.

METHODS

This review is based on pertinent publications retrieved from a selective search in PubMed, on guidelines from Germany and abroad, and on the authors' clinical experience.

RESULTS

Plantar fasciitis is generally diagnosed from the history and physical examination, without any ancillary studies. In 90-95% of cases, conservative treatment (e.g., stretching exercises, fascia training, ultrasound therapy, glucocorticoid injections, radiotherapy, shoe inserts, and shock-wave therapy) brings about total, or at least adequate, relief of pain within one year. Intractable pain is an indication for surgical treatment by plantar fasciotomy and/or calf muscle release. In metatarsalgia, a directed diagnostic work-up to find the cause is mandatory, including a search for excessive mechanical stress due to abnormal foot posture, neuropathic pain, rheumatoid arthritis, aseptic bony necrosis, or malignant disease; imaging studies and pedobarography are needed. For causally oriented treatment, a wide range of conservative and surgical measures can be considered.

CONCLUSION

The reported results of treatments for plantar fasciitis and metatarsalgia are heterogeneous. The efficacy of the individual measures should be studied in randomized controlled trials.

Changes in Rearfoot Alignment in Chronic Plantar Heel Pain

Plantar heel pain is a common disabling condition in adults. Biomechanical factors are important in the development of plantar heel pain. Quantitative changes in rearfoot alignment in patients with plantar heel pain have not been previously investigated. From April 2016 to March 2017, 100 patients with plantar heel pain and 100 healthy individuals were recruited. The foot posture index was used for the measurement of foot alignment. The generalized joint hypermobility condition was assessed using the Beighton scale. The transverse plane talocalcaneal angle, calcaneocuboid angle, talonavicular uncovering angle, calcaneal inclination angle (CIA), talar declination angle, talar-first metatarsal angle, and sagittal talocalcaneal angle were measured on standard weightbearing anteroposterior and lateral foot radiographs. The body mass index was recorded electronically. The distribution of sex, age, weight, body mass index, side, foot posture index score, and Beighton scale were comparable between groups (p > .05). The mean calcaneocuboid angle (p = .009), talonavicular uncovering angle (p = .000), CIA (p = .000), talar declination angle (p = .039), and talar-first metatarsal angle (p = .000) were significantly higher in the plantar heel pain group. In conclusion, our study has demonstrated a relationship between chronic plantar heel pain and the CIA.

American College of Foot and Ankle Surgeons Clinical Consensus Statement: Diagnosis and Treatment of Adult Acquired Infracalcaneal Heel Pain

Adult acquired inferior calcaneal heel pain is a common pathology seen in a foot and ankle practice. A literature review and expert panel discussion of the most common findings and treatment options are presented. Various diagnostic and treatment modalities are available to the practitioner. It is prudent to combine appropriate history and physical examination findings with patient-specific treatment modalities for optimum success. We present the most common diagnostic tools and treatment options, followed by a discussion of the appropriateness of each based on the published data and experience of the expert panel.

Additional diagnostic value of digital radiology in plantar fasciitis diagnosis

Background: Ultrasonography (USG) is regarded as the gold standard to differentiate normal plantar fascia and plantar fasciitis. Conventional radiography or plain X-ray is typically used to exclude differential diagnosis. Lately, conventional radiography has been digitalized and leads to better visualization of the soft tissue. However, it is not known whether digital radiography evaluation for calcaneus area, both qualitative and quantitative, has a similar diagnostic value as USG findings. Therefore, this study aimed to evaluate whether there is a strong correlation between digital radiographic and USG findings for diagnosing plantar fasciitis.Methods: This is a cross sectional study examining adult patients (>18 years old) presenting with inferior heel pain. Plantar aponeurosis thickness was measured by digital radiography and ultrasonography; measurement was performed three times in each modality, and the average value was recorded. Fat stranding, presence of calcaneal enthesophyte, and microfracture were also evaluated in digital radiography. Measurement results were classified into plantar fasciitis diagnosis using the cut-off value 4 mm.Results: There was no significant correlation between plantar aponeurosis thickness measured by digital radiography and by ultrasonography (r=0.069, p=0.688). There was no significant association between plantar fasciitis diagnosis by digital radiography and ultrasonography (p=0.162). However, digital radiography showed good sensitivity to detect plantar fasciitis using a cut-off value of >4 mm plantar fascia thickness.Conclusion: Digital radiography might be used to aid definitive diagnosis for plantar fasciitis.

The plantar calcaneal spur: a review of anatomy, histology, etiology and key associations

The plantar calcaneal spur (PCS) is a bony outgrowth from the calcaneal tuberosity and has been studied using various methods including cadavers, radiography, histology and surgery. However, there are currently a number of discrepancies in the literature regarding the anatomical relations, histological descriptions and clinical associations of PCS. Historically, authors have described the intrinsic muscles of the foot and/or the plantar fascia as attaching to the PCS. In this article we review the relationship between the PCS and surrounding soft tissues as well as examining the histology of the PCS. We identify a number of key associations with PCS, including age, weight, gender, arthritides, plantar fasciitis and foot position; these factors may function as risk factors in PCS formation. The etiology of these spurs is a contentious issue and it has been explained through a number of theories including the degenerative, inflammatory, traction, repetitive trauma, bone-formers and vertical compression theories. We review these and finish by looking clinically at the evidence that PCS causes heel pain.

Diagnosis and management of plantar fasciitis

Plantar fasciitis, a chronic degenerative process that causes medial plantar heel pain, is responsible for approximately 1 million physician visits each year. Individuals with plantar fasciitis experience pain that is most intense during their first few steps of the day or after prolonged standing. The authors provide an overview of the diagnosis and management of a common problem encountered in the primary care setting. Routine imaging is not initially recommended for the evaluation of plantar fasciitis but may be required to rule out other pathologic conditions. Overall, plantar fasciitis carries a good prognosis when patients use a combination of several conservative treatment modalities. Occasionally, referral to a specialist may be necessary.

Emergency Department Extremity Radiographs in the Setting of Pain Without Trauma: Are They Worth the Pain?

BACKGROUND

Few data exist that correlate acute radiographic findings of extremity imaging with patients' complaints in the acute care setting.

OBJECTIVE

We hypothesize that plain radiographs performed for a complaint of pain in the absence of trauma or signs and symptoms of infection are of low yield.

METHODS

We retrospectively analyzed the imaging and charts of 1331 patients who presented to our emergency department (ED) and received extremity radiographs with complaints related to limb trauma, infection, and pain alone. Imaging and outcomes of cases interpreted as positive for acute pathology and those interpreted as indeterminate were analyzed using Fisher's exact tests to evaluate the value of extremity radiographs in the setting of isolated limb pain.

RESULTS

Of the patients analyzed, 935 presented with trauma, 234 presented with nontraumatic pain, and 161 presented with signs or symptoms of infection. The rate of definitively positive cases was 30.6% for trauma, 20.6% for infection, and 1.3% for pain. When indeterminate cases were included in the analysis, the rate of acutely positive cases rose to 33.4% for trauma, 28.0% for infection, and 3.0% for pain. Among the three definitively positive pain cases, all three were fractures, none of which resulted in emergent surgery or orthopedic consults. Among the four indeterminately positive pain cases, three proved to be false positives.

CONCLUSIONS

Our data suggest that ED imaging of patients presenting with nontraumatic pain is of extremely low yield, resulting in few acute positive findings that require immediate attention in the ED.

The treatment of intractable plantar fasciitis with platelet-rich plasma injection

BACKGROUND

Whilst most cases of plantar fasciitis can be settled with existing conservative treatment, a few intractable cases can be difficult to resolve. New biologic treatments have been proposed for a variety of soft tissue problems.

OBJECTIVE

Evaluate the effectiveness of platelet rich plasma (PRP) in chronic cases of plantar fasciitis.

PATIENTS AND METHODS

Patients with plantar fasciitis not responded to a minimum of 1 year standard conservative management were offered PRP therapy. Injections were performed in theatre as a day case. Roles-Maudsley (RM) scores, Visual Analogue Scores (VAS), AOFAS scores and 'would have injection again' were collated pre-operatively, three and six months.

RESULTS

Prospective data was collected of 50 heels (44 patients). At six month review, RM score improved from mean 4 to 2 (p<0.001), VAS improved from 7.7 to 4.2 (p<0.001) and AOFAS improved from 60.6 to 81.9 (p<0.001). 28 patients (64%) were very satisfied and would have the injection again. No complications were reported.

CONCLUSION

In these chronic cases, PRP produce an efficacy rate, approaching 2 out of every 3. The procedure was safe with no reported complications. The authors feel PRP may have some role in treatment, and merits further study with a prospective randomised trial.

The conundrum of calcaneal spurs: do they matter?

BACKGROUND

Chronic plantar heel pain is a common and potentially debilitating condition, often caused by plantar fasciitis. Plantar calcaneal spurs were originally considered the cause of plantar fasciitis but are now regarded as an incidental finding by most authors. We aimed to test this hypothesis and to investigate predisposing factors for the development of spurs.

METHODS

We reviewed all lateral ankle X rays taken in our institution over a 6-month period and identified all X rays demonstrating calcaneal spurs. Then, we identified a similar number of age- and sex-matched controls without spurs. We contacted both groups by telephone and compared symptoms of heel pain, plantar fasciitis, associated comorbidities, and foot and ankle outcome scores (FAOSs).

RESULTS

We reviewed the X rays of 1103 consecutive patients and found a spur prevalence of 12.4%, more common in women and older patients. Questioning of the spur group and control group found a higher body mass index in the spur group. Patients with spurs were 4 times more likely to have diabetes mellitus and 10 times more likely to have lower-limb osteoarthritis. Patients with spurs had more foot pain and poorer FAOS than the control group, even when patients with plantar fasciitis were excluded.

CONCLUSION

Our results demonstrate that the presence of a plantar calcaneal spur may be an indicator of foot pain independent of plantar fasciitis. Although spurs may not cause foot pain themselves, they may be an indication of other associated conditions.

CLINICAL RELEVANCE

We have demonstrated the relevance of a radiographic finding once considered irrelevant.

The effect of foot arch on plantar pressure distribution during standing

The aim of this study was to explore how foot type affects plantar pressure distribution during standing. In this study, 32 healthy subjects voluntarily participated and the subject feet were classified as: normal feet (n = 23), flat feet (n = 14) and high arch feet (n = 27) according to arch index (AI) values obtained from foot pressure intensity image analysis. Foot pressure intensity images were acquired by a pedopowergraph system to obtain a foot pressure distribution parameter-power ratio (PR) during standing in eight different regions of the foot. Contact area and mean PR were analysed in hind foot, mid-foot and fore foot regions. One-way analysis of variance was used to determine statistical differences between groups. The contact area and mean PR value beneath the mid-foot was significantly increased in the low arch foot when compared to the normal arch foot and high arch foot (p < 0.001) in both feet. However, subjects with low-arch feet had significantly higher body mass index (BMI) compared to subjects with high-arch feet (p < 0.05) and subjects with normal arch feet (p < 0.05) in both feet. In addition, subjects with low-arch feet had significant differences in arch index (AI) value as compared to subjects with high-arch feet (p < 0.001) and subjects with normal arch feet (p < 0.05) in both feet. Mean mid-foot PR value were positively (r = 0.54) correlated with increased arch index (AI) value. A significant (p < 0.05) change was obtained in PR value beneath the mid-foot of low arch feet when compared with other groups in both feet. The findings suggest that there is an increased mid-foot PR value in the low arch foot as compared to the normal arch foot and high arch foot during standing. Therefore, individuals with low arch feet could be at high risk for mid-foot collapse and Charcot foot problems, indicating that foot type should be assessed when determining an individual's risk for foot injury.

Intraosseous lipoma of the calcaneus mimicking plantar fascitis

Benign lytic lesions of the calcaneus are rare and are usually asymptomatic. We report this case of a 55-year-old man with bilateral non-traumatic plantar heel pain, which was treated conservatively as plantar fasciitis. At three months follow-up, the patient had complete relief of symptoms in the left heel with partial relief of symptoms on the right side. However under the insistence of the patient an X-ray was taken, which revealed an expansile lytic lesion of the right calcaneus and a normal left heel. CT-scan revealed an expansile lytic lesion on the right calcaneus and an early lytic lesion in the left calcaneus. Following surgical intervention, the diagnosis was confirmed as intra-osseous lipoma and the patient was completely symptom free at two-year follow-up. Patients presenting with non-traumatic heel pain should be explained about the possible causes of heel pain, and should be offered X-ray at the first visit. In patients with X-ray showing unilateral lipoma of the calcaneus, CT scan should be offered to rule out involvement of the opposite side.

Plantar heel pain

Plantar fasciitis is a common problem without known etiology. It responds well to multiple conservative modalities and no particular modality has been demonstrated to be clearly superior in the treatment of this condition. Over 90% of patients will be cured by non-operative treatment but this may require 6 to 12 months of treatment and encouragement by the physician. Extracorporeal shock wave therapy is a noninvasive treatment with a success rate comparable to surgery and a low complication rate. Surgery can be done endoscopically or open with similar long-term outcomes. Patients appear to recover from endoscopic treatment 4 to 5 weeks earlier than the open group. If there is a suggestion of FBLPN entrapment, then patients should have an open release.

Plantar fasciitis: evaluation and treatment

Plantar fasciitis is the most common cause of plantar heel pain. Its characteristic features are pain and tenderness, predominately on the medial aspect of the calcaneus near the sole of the heel. Considering a complete differential diagnosis of plantar heel pain is important; a comprehensive history and physical examination guide accurate diagnosis. Many nonsurgical treatment modalities have been used in managing the disorder, including rest, massage, nonsteroidal anti-inflammatory drugs, night splints, heel cups/pads, custom and off-the-shelf orthoses, injections, casts, and physical therapy measures such as shock wave therapy. Most reported treatment outcomes rely on anecdotal experience or combinations of multiple modalities. Nevertheless, nonsurgical management of plantar fasciitis is successful in approximately 90% of patients. Surgical treatment is considered in only a small subset of patients with persistent, severe symptoms refractory to nonsurgical intervention for at least 6 to 12 months.