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41 ST Annual Goldfarb Clinical Conference Valley Forge Casino Resort King of Prussia, PA James A Marks, DPM, FACFAS, FAPWCA James A Marks, DPM, FACFAS,

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Presentation on theme: "41 ST Annual Goldfarb Clinical Conference Valley Forge Casino Resort King of Prussia, PA James A Marks, DPM, FACFAS, FAPWCA James A Marks, DPM, FACFAS,"— Presentation transcript:

1 41 ST Annual Goldfarb Clinical Conference Valley Forge Casino Resort King of Prussia, PA James A Marks, DPM, FACFAS, FAPWCA James A Marks, DPM, FACFAS, FAPWCA Medical Director, The Wound & Skin Healing Center of Washington Health System Foot and Ankle Specialists / Washington Physicians Group 11-08-13

2 Employed by Washington Health System & Washington Physicians Group Speakers Bureau for Shire Regenerative Medicine Father of 4 ~ Lucas Grandfather Well done is better than well said. ~ Benjamin Franklin James A. Marks DPM, FACFAS, FAPWCA

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4 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

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6 James A Marks, DPM Fellow, American College of Foot and Ankle Surgeons

7 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 www.pennfoot.com

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9 www.pennfoot.com

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11 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

12 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.

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

14 Kelton Research 1,082 surveyed James A Marks, DPM, FACFAS, FAPWCA

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16 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 www.pennfoot.com

17 Mechanical Neurological Rheumatological Traumatic Infectious Metabolic Neoplastic James A Marks, DPM, FACFAS, FAPWCAwww.pennfoot.com

18 Mechanical primarily plantar fasciosis primarily plantar fasciosisNeurological primarily nerve entrapment primarily nerve entrapmentRheumatological primarily seronegative arthritides www.pennfoot.com James A Marks, DPM, FACFAS, FAPWCA

19 Plantar fasciitis Heel Spur Syndrome Inferior calcaneal bursitis Policemans Heel Heel bruise Policemans Heel Stress Fracture Fat pad pathology Chronic compartment syndrome James A Marks, DPM, FACFAS, FAPWCAwww.pennfoot.com

20 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, FAPWCAwww.pennfoot.com

21 Pain Pain on standing, especially after periods of inactivity or sleep Pain Pain subsides, returns w activity Pain Pain related to footwear – can be worse in flat shoes w no support pain Radiating pain to the arch & toes pain In later stages, pain may persist/progress throughout the day Pain pain 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, FAPWCAwww.pennfoot.com

23 HistoryPhysicalImaging Blood tests For inflammatory arthritis Nerve conduction studies For nerve pathology www.pennfoot.comJames A Marks, DPM, FACFAS, FAPWCA

24 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

25 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 persons weight or activity? What relieves the pain? What has the patient already tried? www.pennfoot.com James A Marks, DPM, FACFAS, FAPWCA

26 Palpation Range of motion Functional testing www.pennfoot.com James A Marks, DPM, FACFAS, FAPWCA

27 (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

28 www.pennfoot.comJames A Marks, DPM, FACFAS, FAPWCA

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

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

31 Plain Films www.pennfoot.com

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

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

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

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37 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

38 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

39 NSAIDs Cortisone injection ??? Air-heel brace, heel cup, heel lifts OTC Orthotics, etc. Patient education: 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 Y OU ARE NOW 3-4 WEEKS PAIN LEVEL 5 OR Y OU ARE NOW 3-4 WEEKS PAIN LEVEL 5 OR Reassess exam and review testing results Patient education reinforcement 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

41 Y OU ARE NOW 7-8 WEEKS PAIN LEVEL 5 OR : Reassess exam and chief complaint Patient education reinforcement 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

42 Y OU ARE NOW 3-6 MONTHS PAIN LEVEL 5 OR : Reassess exam & chief complaint Any additional testing needed? Patient education reinforcement Patient education reinforcement Cortisone injection ?? NSAID adjustment (oral & topical) Immobilization Surgical intervention Referral James A. Marks DPM, FACFAS, FAPWCA www.pennfoot.com

43 Shockwave treatment Topaz (Coblation) Platelet Rich Plasma Injection

44 James A Marks, DPM, FACFAS, FAPWCAwww.pennfoot.com

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