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

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

1984 PHOP RESIDENTS

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

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

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 

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

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

YOU ARE NOT ALONE

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

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.

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

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

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 

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

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

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

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

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

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

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

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

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

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

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

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

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

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 www.pennfoot.com

IMAGING Plain Films www.pennfoot.com

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

IMAGING 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

TREATMENT

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

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

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 www.pennfoot.com

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

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

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

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

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

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

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

Live life with no regrets…

Wilfred R. Cameron Wellness Center 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