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HEEL PAIN – “For the Record” A Community Presentation

HEEL PAIN – “For the Record” A Community Presentation. 41 ST 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

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HEEL PAIN – “For the Record” A Community Presentation

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  1. HEEL PAIN – “For the Record”A Community Presentation 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

  2. PRESENTER DISCLOSURE 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

  3. 1984 PHOP RESIDENTS

  4. 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

  5. HEEL PAIN AMERICA’S #1 FOOT AILMENT James A Marks, DPM  Fellow, American College of Foot and Ankle Surgeons

  6. OBJECTIVES OF THIS LECTURE Causes of Heel pain How to self treat before calling a Podiatrist Heel pain work-up Discuss treatment New treatments Surgical options • www.pennfoot.com James A Marks, DPM, FACFAS, FAPWCA 

  7. DOC, THIS IS WHERE IT HURTS! James A Marks, DPM, FACFAS, FAPWCA 

  8. WHY? • James A Marks, DPM, FACFAS, FAPWCA  • www.pennfoot.com

  9. YOU ARE NOT ALONE

  10. 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

  11. 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 www.pennfoot.com • Buchbinder, R. N Eng J Med. 2004; 350: 2159-66.

  12. APMA Foot Ailments Survey January 2009 www.pennfoot.com James A Marks, DPM, FACFAS, FAPWCA 

  13. APMA FOOT AILMENTS SURVEY JANUARY 2009 • Kelton Research 1,082 surveyed James A Marks, DPM, FACFAS, FAPWCA 

  14. HEEL PAIN SYNDROME Plantar fasciitis/iosis Plantar fibromatosis Stress fracture Nerve entrapment Trauma Calcaneal apophysitis Tarsal tunnel syndrome Calcaneal bone cysts / tumors www.pennfoot.com • James A Marks, DPM, FACFAS, FAPWCA 

  15. THERE ARE MANY CAUSES Mechanical Neurological Rheumatological Traumatic Infectious Metabolic Neoplastic www.pennfoot.com James A Marks, DPM, FACFAS, FAPWCA

  16. PRIMARY CAUSES Mechanical  primarily plantar fasciosis Neurological  primarily nerve entrapment Rheumatological  primarily seronegativearthritides www.pennfoot.com James A Marks, DPM, FACFAS, FAPWCA

  17. MECHANICAL Plantar fasciitis Heel Spur Syndrome Inferior calcaneal bursitis Heel bruise “Policeman’s Heel” Stress Fracture Fat pad pathology Chronic compartment syndrome www.pennfoot.com James A Marks, DPM, FACFAS, FAPWCA

  18. 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 www.pennfoot.com James A Marks, DPM, FACFAS, FAPWCA

  19. Plantar Fasciitis* • Painon standing, especially after periods of inactivity or sleep • Pain subsides, returns w activity • Painrelated to footwear – can be worse in flat shoes w no support • Radiating pain to the arch & toes • In later stages, painmay 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

  20. www.pennfoot.com • James A. Marks DPM, FACFAS, FAPWCA

  21. MAKING the DIAGNOSIS History Physical Imaging Blood tests For inflammatory arthritis Nerve conduction studies For nerve pathology www.pennfoot.com James A Marks, DPM, FACFAS, FAPWCA

  22. 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

  23. 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

  24. PHYSICAL EXAM Palpation Range of motion Functional testing • www.pennfoot.com James A Marks, DPM, FACFAS, FAPWCA

  25. Maximal tenderness • 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

  26. PALPATION • www.pennfoot.com James A Marks, DPM, FACFAS, FAPWCA

  27. PALPATION James A Marks, DPM, FACFAS, FAPWCA • www.pennfoot.com

  28. IMAGING Plain film X-rays Generally the starting point Bone scans Increased bone turnover Ultrasonography Soft tissue problems CT Scan MRI • www.pennfoot.com

  29. IMAGING • Plain Films • www.pennfoot.com

  30. IMAGING • Tech Bone Scan • www.pennfoot.com James A Marks, DPM, FACFAS, FAPWCA

  31. IMAGING MRI: T1 MRI: T2 fat suppressed sagittal image abnormal signal in proximal plantar fascia and bone marrow edema James A Marks, DPM, FACFAS, FAPWCA • www.pennfoot.com

  32. TREATMENT

  33. Ever felt like you're in a pickle? www.pennfoot.com • James A. Marks DPM, FACFAS, FAPWCA

  34. We Are…WHS/Foot & Ankle Specialists www.pennfoot.com James A. Marks DPM, FACFAS, FAPWCA

  35. SELF TREATMENT • 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 • www.pennfoot.com

  36. PROPER SHOE GEAR • 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! www.pennfoot.com

  37. FIRST VISIT 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 Reappoint in 3 weeks • James A. Marks DPM, FACFAS, FAPWCA

  38. SECOND VISIT 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 www.pennfoot.com • James A. Marks DPM, FACFAS, FAPWCA

  39. THIRD VISIT 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 www.pennfoot.com • James A. Marks DPM, FACFAS, FAPWCA

  40. FOURTH VISIT 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 James A. Marks DPM, FACFAS, FAPWCA • www.pennfoot.com

  41. NEW TREATMENT OPTIONS Shockwave treatment Topaz (Coblation) Platelet Rich Plasma Injection

  42. TAKE HOME MESSAGE www.pennfoot.com James A Marks, DPM, FACFAS, FAPWCA

  43. Live life with no regrets…

  44. THANK YOU For more information… 724-222-5635 Monday through Friday 8 am – 4:30 pm Wilfred R. Cameron Wellness Center 208 Wellness Way, Bldg.1

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