Dr. Timothy Epting, Foot Pain

Quite a bit to go over in a short amount of time. So we’re gonna go on to foot pain.
So from heel pain to foot pain we’ll start off with subcalcaneal Heel pain. Any age it affects anybody young to old, usually more active populations. Patients come into the office it’s kind of that universally despised patients hate it; we hate it but it is very common. So plantar fasciitis is the most common cause. It’s generally misunderstood and overly treated. Also includes other things we’ll talk about is nerve compression as lateral plantar of lateral plantar or nerve compression stress fractures and fat pad atrophy. So Evan kind of alluded a little bit earlier about the plantar fascia the anatomy and it really originates off of the medial calcaneal tuberosity so people think about the plan or fashion everybody comes into office and they say well I have a heel spur. And so the spur is actually not the medial to porosity so they’re two different they’re two different things plantar fasciitis is really more of the micro stairs near the insertion of the plantar fasciitis and it’s more of traction periostitis.
So this goes onto the heel spur. It’s always the great you can’t wait to see that x rays. I was told to have spurs and they need to come off but the heel spurs they don’t cause plantar fasciitis they probably caused by similar repetitive loading mechanisms more in the flexor to the toes and so again it’s mentioned that the heel spurs they’re not the attachment for the plantar fasciitis that medial tubercle of the calcaneus. So just some numbers one in 10 people have heel spurs. 1 in 20 of those with heel spurs have heel pain. So there’s a lot of Spurs running around out there that aren’t painful. The heel pad this is sort of an ingenious cushioner of the foot, it’s an elastic fibrous tissue that forms a honeycomb pattern around the fat in the foot which makes it a really good shock absorber. One of the things that does happen though is with age we have less college in and water content and so less the last test less elasticity and we get fat pad atrophy also which is a normal part of the aging process. We could find a way to put it back in. We’ll be sitting out on the patio drinking umbrella drinks.
So again, for history physical you know for the plantar fasciitis the pain that Devin alluded to is more that can enter immediately based heel pain. The presentation is it’s generally worse in the morning first getting out of bed after getting up after any prolonged sitting and it does progress as they go on throughout the day and they’ll get sore at night and it can be that bad that they just they won’t bear weight on it as you question more neurotic type pains you think about impingement whether it’s task or tunnel Baxter’s neuropathy also lumbar as well so to no signs like we mentioned earlier about the medial ankle you think about tarsal tunnel.
Other things are the calcaneaous stress fractures so part of the history there is as an athlete they increase their training regimen increase their mileage running. In a relatively acute onset of pain it was a gradual progression and then the heel squeeze that we alluded to earlier. They’re all concerning for a stress fracture. So treated differently. As far as imaging usually x rays kind of start off with you can see fractures or sometimes stress fractures that are chronic but if you’re not sure bone scan is an easy test to order. Oftentimes people will write the MRI study however this can give you two pieces of information. You can see the thickening of the plantar fascia sometimes you can see some little intrasubstance signal changes and small tears and you can also see the marrow edema if it’s present for a calcaneaous stress fracture. In these It doesn’t show the marrow edema so this is really more indicative of plantar fasciitis where it’s thick and see some interest substance signal changes and on the right the T two weighted images there’s a little bit of edema down the insertion where the arrows point. To start with the news the nerves nearby briefly hit on these but the medial calcaneal branch innovates the heel skin there’s. Medial plantar, lateral plantar, and in the first branch of the lateral plantar is Baxter’s nerve which has a mixed motor and sensory.
So the first branch the Baxter’s nerve can get trapped between the ascia of the abductor hallucis and the FDB. If we do think it’s a nerve issue EMG nerve conduction studies are an important part because it will detect the the tarsal tunnel.
Also you can see the lateral and medial calcaneal branches that are affected so this can help to either rule in or rule out this problem. Other things again we start to think higher up spine etiology. Also infections, diabetics, they’re insensate. If they step on things don’t realize it and you don’t have pain sometimes, they’ll get pain when they have an infection.
So for plantar fasciitis the orthopedic treatments that we generally recommend, heel cups are a symptomatic treatment helps to relieve some of the pressure on the heel. Oftentimes the source of this issue that drives the plants or fashion is it’s an overstressed of the plantar fascia from a tight gastric. So with that silver scold test that was mentioned earlier you can delineate tight gastric. In part what we do to work on that is a nice splint like we see on the far left. And you can see the oblique straps on the side so the key to it is to get patients to actually use it if they’re having to adjust those straps. It’s not meant to stretch them at night it’s meant to just keep their foot from drooping down into a fully plant or flex position because then when they get up first thing in the morning they’re stretching the gastric and Achilles complex also the plantar fascia and then also as plantar fascia specific exercises almost always we see it in combination with gastric contracts so specific stretches tailored to the gastric other things.
Oftentimes the start with the Home program but off that when the refractory will integrate physical therapy as well depending if there’s been a long they’ve been dealing with it for a long time sometimes therapy will integrate a little bit earlier but they’ll ensure that we get a good technique with stretching because we’ll show I’m in the office giving a handout. But then they go home and they come back in four weeks or six weeks and say it still hurts but they’re doing it wrong. So modalities without to freezes or ultrasound, Graston are really great technique for the gastric contractions as well as if they have more of a mid-substance plantar fascia. So if their pain is in the plantar fascia oftentimes refer for that as well. Injections people get cortisone injections all the time cortisone injections are really a small part of my practice because there’s a downside to it. We talked about the heel pad and cortisone will atrophy the normal fat in your feet.
So if you start getting multiple injections you’re going to atrophy your normal your normal cushion and heel shock absorber. So there was there’s some studies looking at Amnion and placebo and foot and ankle International in 2018 they had a randomized trial where they had significant difference in improved pain and functional scores.
Again these are still considered experimental PRP also had some more effecting more effective and lasting benefits versus cortisone and that was from the study in 2014. About 90 percent of patients respond. Sometimes it takes a while with the stretching programs generally integrating all those together usually give patients an expectation of about 20 percent improvement over the first month of six weeks and then gradually improve thereafter. So it’s really self-limiting. Again as long as we work on the underlying cause if they do have type gastric and again we tell our treatments to the diagnosis so plantar fasciitis majority non operative they do have a nerve and treatment usually will treat them not accurately unless they have a mass occupying lesion in the tarsal tunnel and about three to six months if there’s no improvement. Think about nerve decompression and then stress fractures we treat like a fracture we immobilized take the weight off that pad atrophy. They need more cushioning those gel cups sometimes some custom inserts from the usual doom from the worth of tests but like inserts we use for diabetics that are dual layer foam that helps to add some cushion where they don’t have it.
So just the surgical treatments really for planar fasciitis haven’t released any plan of fashion in five years of doing just put an ankle. Majorities do respond. Occasionally with a real tight gastric have done a gastric recession for.
But for the Associated issues Tarsal tunnel there’s just a demonstration of partial time release and then further distilling is where you find that the terminal branches into a fully release not just the tunnel but release the terminal branches is a complete treatment, we’ll kind of move towards the fore foot now. We’ll head on how its rigidity. This is what people kind of think of they have this bump on the top of my foot so every bump is called a bunion generally. So this is the dorsal bunions the bunion on the top of your foot. Generally, they’re paying with raising up on their tiptoes reaching into a cabinet their stiffness and pain with motion oftentimes just due to previous injury sometimes it could be due to an underlying rheumatologic gout is pretty common as well. Or just general away so in the office your physical exam you’ll see just kind of going back.
They have that bump on the top. They’ll have limited motion and if it’s unilateral and compared to the other side as well. Usually terminal plantar or terminal Dorsiflexion extending the toe is when they’ll be more symptomatic because they have that that spur on the top of the metatarsal and failings. So treatments generally start off with non-surgical treatments accommodative footwear a little wider deeper toe box to accommodate for the bump a softer shoe. Also, if it’s more with the flexion and mobility for exercise this is an example of a turf toe plate. So this is a carbon fiber a little more expensive than a steel one. But if they’re exercising when it will last longer and provide the same relief. So the idea is to mobilize the arthritic joint and then operate treatments for these early on if there’s mostly the dorsal spur and the joints surface is relatively preserved we basically just take off the bump on the top.
There are some implant options with joint replacements. They’re not really good long-term study on joint replacements. There’s a synthetic implant that’s shown some promise but there’s also been some questions about it as well as its effectiveness. And then fusions the other options too. There are pictures of post-surgical. There are other methods we use. These are some older techniques but patients get back to normal activities. So after infusion people have gotten back to running. The big thing that I counsel patients on for fusions especially the female population if you’re wearing heels nothing more than a two-inch heel. Some people don’t want agree to that. And then we have to think about other options staining the fore foot we’ll move a little bit more central lateral neuromas typically called Morton’s neuroma or just interdigital neuroma. It’s involving the common digital nerve that runs beneath the transverse metatarsal ligament between men star cells and then it gives its branches to the to the respective digits.
Most commonly in females unilateral and the third web space. The symptoms generally its plantar pain. They feel like they’re walking on something a pebble a stone in their shoe and they just can’t get it out. Sometimes a burning pain radiates into the toes. Something may be moving in the foot or that again they feel like they have something in their shoe type shoes make it worse. So people trying to cram into a skinny tight shoe pointy shoes they compress the metatarsal and they kind of mimics that moulderrs test. That was mentioned earlier. Also the heels will put more higher heel will put more pressure on the four foot as well trapping the nerves so bare feet soft soled shoes usually help better or sandals that are open toed. So with the physical exam they’re having that plantar tenderness and this is a picture kind of depicting you know popping the metatarsal heads themselves versus the space between them and it’s hard to feel a palpable mass unless they’re really large. You won’t usually feel a mass but the Mulder sign is when they get the click and they were reproducible pain when you’re compressing the metatarsals together and numbness is really a rare finding.
So diagnostic studies x rays we start off with sometimes there’s associated pathology or other things that could be causing the problem as well. And this is just metatarsophalangeal joint instability. That’s one of the issues with multiple cortisone injections you can weaken the collateral ligaments. So if you have multiple injections you can end up with toe deformities that were a result of injections to treat a different problem. Ultrasound MRI these can confirm. The neuroma injections selective can be helpful you can do diagnostic with just lidocaine or You can do a non-guided or ultrasound guided would be my preference because you can really target the nerve and just use a small amount.
And again these are just sort of the different things that can mimic or cause some of that for foot pain some sort of virus. Again we talked about the fat pad degeneration happens in the four foot as well as the hind foot fibers and fraction is a gene across is typically the second metatarsal head where they get flattening and some early degenerative changes. Again, we think about neurologic and other tumors that could be an issue as well. The non-surgical treatments for the neuromas is a wider soft lace shoe with a low heel again avoiding that lowering of the ball or fore foot. Menopausal pads, the green pictured has a picture of the metatarsal pad that we typically put in the shoes. It sticks to the shoe not the patient’s foot. Some people stick these things to their foot and we just let them know that it goes in the shoe again steadily injections.
Very selective. These are things that I’ll do once and if they get relief and it doesn’t last. Know we think about other things like surgery or just the shoe modification if it does enough for those are the side effects of the steroid injections the fat atrophy. You do get the skin discoloration that was mentioned in the hand lectured her hand lectures earlier and then joined caps on collateral ligament degenerative changes that can result in instability. So for surgical excised and aroma use your dorsal incision to take out the nerve plantar if they get a scar that caused the painful scar and there’s no way to fix a painful scar. Well you can revise it but you can have another painful scar. And so surgeons surgical treatments about 80 percent with the first time treatment and non-revision is 80 percent success. People have complete resolution 20 percent or 10 percent had partial and another 10 have been complete really for no relief.