1. HEEL PAIN – “For the Record” A Community Presentation
41ST Annual Goldfarb Clinical Conference Valley Forge Casino Resort King of Prussia, PA
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
James A. Marks DPM, FACFAS, FAPWCA

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

7. 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
James A Marks, DPM, FACFAS, FAPWCA 

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

9. WHY?
James A Marks, DPM, FACFAS, FAPWCA 

10. YOU ARE NOT ALONE

11. 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 

12. 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
Buchbinder, R. N Eng J Med. 2004; 350:

13. APMA Foot Ailments Survey January 2009
James A Marks, DPM, FACFAS, FAPWCA 

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

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

17. THERE ARE MANY CAUSES
Mechanical Neurological Rheumatological Traumatic Infectious Metabolic Neoplastic
James A Marks, DPM, FACFAS, FAPWCA

18. PRIMARY CAUSES Mechanical  primarily plantar fasciosis Neurological
 primarily nerve entrapment
Rheumatological
 primarily seronegative arthritides
James A Marks, DPM, FACFAS, FAPWCA

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

20. 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
James A Marks, DPM, FACFAS, FAPWCA

21. Plantar Fasciitis*
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
*First described by Woods, 1812

22.
James A. Marks DPM, FACFAS, FAPWCA

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

24. HISTORY
Location of pain? Nature of pain? Duration of pain? When does the pain occur? Age, physical make-up, activities?
James A Marks, DPM, FACFAS, FAPWCA

25. 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?
James A Marks, DPM, FACFAS, FAPWCA

26. PHYSICAL EXAM Palpation Range of motion Functional testing
James A Marks, DPM, FACFAS, FAPWCA

27. 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

28. PALPATION
James A Marks, DPM, FACFAS, FAPWCA

29. PALPATION
James A Marks, DPM, FACFAS, FAPWCA

30. IMAGING Plain film X-rays Bone scans Ultrasonography CT Scan MRI
Generally the starting point
Bone scans
Increased bone turnover
Ultrasonography
Soft tissue problems
CT Scan
MRI

31. IMAGING
Plain Films

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

33. 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

34. TREATMENT

35. Ever felt like you're in a pickle?
James A. Marks DPM, FACFAS, FAPWCA

36. We Are… WHS/Foot & Ankle Specialists
James A. Marks DPM, FACFAS, FAPWCA

37. 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
Steroid injections , Physical therapy
If conservative measures fail, surgery is an option

38. 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!

39. 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

40. 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
James A. Marks DPM, FACFAS, FAPWCA

41. 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
James A. Marks DPM, FACFAS, FAPWCA

42. 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

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

44. TAKE HOME MESSAGE
James A Marks, DPM, FACFAS, FAPWCA

45. Live life with no regrets…

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