Heel Pain DISCLOSURES. John Tennity, D.P.M. I have no financial disclosures or conflicts of interest

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1 Heel Pain John Tennity, D.P.M. DISCLOSURES I have no financial disclosures or conflicts of interest 1

2 What is the Most Common Form of Heel Pain? A. Neurologic B. Arthritic C. Mechanical D. Traumatic 2

3 Plantar Fasciitis Heel Spur Syndrome Classic Plantar Fasciitis 3

4 Classic Symptoms Pain on plantar medial heel after rest Post Static dyskinesia First steps out of bed After lunch End of day Risk Factors Poor Shoe Gear Barefoot Obesity Work New workout (Crossfit, etc.) 4

5 Weight Bearing Lateral Anatomy 5

6 Ultrasonography 6

7 Too Much Cortisone Posterior Heel Pain Insertional Achilles tendinopathy, aka Achilles enthesiopathy Haglund s deformity pump bump Retrocalcaneal bursitis Achilles tendinitis 7

8 Insertional Achilles + Haglund s Achilles Tendinitis Much more superior Often at watershed area Palpate for partial tear Strength testing 8

9 Other Causes of Heel Pain Neurologic Traumatic Arthritic Other Neurologic Radiating pain Burning, tingling, paresthesia's Sensory abnormalities Positive Tinel s sign Electro diagnostic studies Neurology referral 9

10 Neurologic Pathology Tarsal tunnel syndrome Entrapment neuropathy Radiculopathy Disc disease Systemic neuropathies Traumatic History of trauma Global pain with compression Pain worsens with activity History of stepping on something 10

$Stress fracture$ Foreign body

11 Stress fracture Acute fracture Foreign body Contusion Traumatic Trauma 11

12 Foreign Body Most Common Foreign Body I Remove is. A. Glass B. Metal C. Hair D. Wood 12

13 Arthritic Inflammatory arthritides Often associated with other joint pain or swelling Radiographs Imaging studies Laboratory testing Associated Arthritides Rheumatoid arthritis Ankylosing spondylitis Reiter s disease Lupus Gout Psoriasis Fibromyalgia 13

14 Other Causes of Heel Pain Tumors Infection Vascular disease Calcaneal apophysitis Fat pad atrophy Infection 14

15 The Solution to Pollution is Dilution Which of the Following is a Contraindication to Incision and Drainage in the Office? A.Pulsatile mass B. Diabetes C. Vascular disease D.Immunocompromised patient 15

16 Calcaneal Apophysitis Tumors 16

17 What Was That Bone Tumor? A.Osteochondroma B. Aneurysmal bone cyst C. Osteoid osteoma D.Unicameral bone cyst E. Osteosarcoma Ingrown Toenails John Tennity, D.P.M. 17

18 Classic Paronychia 18

19 Classic Paronychia Granuloma 19

20 Phenol Matrixectomy The gold standard Low recurrence rate Minimal postop discomfort Easy postop course May get wet postop High patient satisfaction 20

21 Toenail Anatomy Dr. John Tennity, DPM Normal Anatomy 21

22 Digital Block 3 cc s per toe Remember, most of the toe distal sensation comes from the plantar nerves Use a plantar block if needed to augment Simple Effective Use 1 or 2 % Xylocaine 27 or 30 gauge needle For longevity add 0.5 % Marcaine (50/50 mix) NO EPI in digits Digital Block 22

23 Great Toe Injection 5 th Toe Injection 23

Free Up The Nail or Border Atraumatic technique Use a spatula/packer Free

24 Tourniquet Hemostasis is critical to prevent recurrence Blood will dilute the phenol Need a dry field Curved stat and Penrose drain Exsanguinate Free Up The Nail or Border Atraumatic technique Use a spatula/packer Free all sides With a partial matrixectomy, keep the remaining nail firmly attached 24

straight Kelly hemostat and roll the nail towards the toe midline when removing the nail

25 Nail Splitting Use an English anvil nail splitter if available Try not to loosen the adjacent toenail Take it all the way back under the eponychium Nail Splitting Use appropriate sized straight Kelly hemostat and roll the nail towards the toe midline when removing the nail Currette the matrix to roughen it up for phenol application AND to check for incomplete nail plate extraction 25

26 Hemostasis Lumicain Silver nitrate (not as good, leaves the area black) Phenol Application Use 1-2 drops of 80% aqueous phenol Must not be old Use a mini applicator for precision Apply to nail bed and matrix 26

27 Phenol Application Be careful!!!! Highly caustic Protect all tissues you do not want phenol to touch, including your own Partial = 3 applications for seconds Total = 5 applications for seconds Phenol Application Don t just hit the matrix! Cauterize the nail bed also, it has germinal matrix too! 27

28 Isopropyl alcohol Use plenty Neutralizes the phenol Stops the chemical cauterization Alcohol Flush Finish Inspect for remaining debris Apply betamethasone cream and triple antibiotic Gauze dressing anchored with tape 28

Finish Inspect for remaining debris Apply betamethasone cream and triple antibiotic Gauze dressing anchored with tape Postop Course Oral antibiotics PRN B.I.D.

29 Finish Inspect for remaining debris Apply betamethasone cream and triple antibiotic Gauze dressing anchored with tape Postop Course Oral antibiotics PRN B.I.D. dressing changes after a cool water soak for 5-15 minutes starting one day postop Triple antibiotic ointment and bandaid usually sufficient Continue until drainage stops Usually 3-6 weeks 29

30 Let s Do One Needs a Total 30

31 Healthy Feet are 31

Index. Clin Podiatr Med Surg 22 (2005) Note: Page numbers of article titles are in bold face type.

Index. Clin Podiatr Med Surg 22 (2005) Note: Page numbers of article titles are in bold face type. Clin Podiatr Med Surg 22 (2005) 137 141 Index Note: Page numbers of article titles are in bold face type. A Achilles tendinopathy, 19 43. See also Achilles classification of, 20 differential diagnosis