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Description: The OPMA has taken the past 10 years of articles, media clips, foot health facts and general public information and bundled them in year groupings for ease of reference. There are 3 additional parts to this series.
Foot Health Advice 1993-1995 Foot Health Advice 1993-1995 Contents Heel Pain Syndrome ............................................................................................................................ 2 Ulcerations Affecting the Lower Extremities ................................................................................ 4 Heel Pain What Causes It ............................................................................................................... 5 Foot Surgery The Minimal Incision Approach .............................................................................. 6 1 Foot Health Advice 1993-1995 Heel Pain Syndrome Introduction Endoscopic Plantar Fasciotomy is a recent medical breakthrough for treatment of painful heels. Often called heel spur syndrome Plantar Fasciitis can now be corrected easily in our clinic. The technique (EPF) was introduced to Canada in 1993 by Hartley Miltchin D.P.M. who is considered to be the Canadian leader in this procedure. The EPF procedure is utilized to correct chronic heel pain that afflicts men and women equally. As opposed to traditional hospital correction EPF allows for much quicker recovery and faster return to normal activity. What is Plantar Fasciitis or Heel Spur Syndrome Heel pain is usually present during the first few steps in the morning and tends to ease until the next time the patient rests sits or drives and tries to stand on their feet. Many patients describe this pain as a hot knife being pushed into my heel. If left untreated pain can become constant even hurting when at rest. For some patients the pain is so severe they can no longer participate in certain normal activities such as work and sports. What Causes It Plantar Fasciitis (heel Pain) is caused by a mechanical imbalance in the foot called pronation. Over-pronation causes the foot to roll in towards the arch and big toe area. There is a very strong fibrous band on the bottom of the foot called the Plantar Fascia. The Plantar Fascia inserts in the heel bone and then spreads out and joins the toes. When the foot rolls in (pronates) the band must try and stretch but it cannot therefore the fascia pulls at it s insertion at the heel bone which causes swelling hence pain. Over time as the fascia continually pulls it pulls away at the bone causing a heel spur. The size or presence of a heel spur does not always correlate with the amount of pain. One can have a heel spur with the absence of pin and vice versa Will It Go Away This is possible in some patients however it will tend to return much worse than the first episode. In most cases the longer it is left untreated the more chronic the condition and the more difficult it is to treat. Am I a Candidate for the Surgical Procedure (EPF) If you have failed to obtain complete relief of the heel pain with the use of conservative treatments such as heel taping cortisone injections anti-inflammatory medicines physical therapy or PRESCRIPTION ORTHOTICS then you may benefit from Endoscopic Plantar Fasciotomy. Remember almost all patients are treated satisfactorily with proper PRESCRIPTION ORTHOTICS alone. Orthotics are required pre and post operatively. A complete consultation and examination will help determine your best option. What Then If all of your symptoms go away with conservative care then surgery will not be necessary. If however pain and discomfort are still present after conservative treatment has been tried then surgery is recommended. How Is This Procedure Different In traditional Planter Fascia Surgery a large open incision is made to release the tight fascia band and remove the heel spur if present. Studies have proven that the heel spur itself does not hurt but rather the inflammatory response due to the constant pulling is what hurts. Consequently spur removal I not necessary when Endoscopic Plantar Fasciotomy is utilized. 2 Foot Health Advice 1993-1995 EPF is performed by inserting a highly specialized micro camera into the heel area visualizing the fascia and detaching a portion of it from the heel bone where it is pulling. Usually 5 or 6 stitches are required. What Results Can I Expect Most patients return to their regular shoes in 1-3 days. Most patients return to work after the first week and return to sports activities after 6 weeks. Everyone heals differently. Other factors such as severity of condition age weight and occupation can contribute to healing times. Patients can feel relief anywhere from one day to one year. What Are The Risks Fortunately there are few complications that can be resolved by careful post-operative treatment. As with all surgery no procedure is risk free and there is absolutely no guarantee as to its success. The most common risks inherent to this procedure include infection numbness delayed healing with aching in the heel or instep area. Hartley Miltchin D.P.M. 1993 by Hartley Miltchin D.P.M. 3 Foot Health Advice 1993-1995 Ulcerations Affecting the Lower Extremities An ulcer unlike other wounds involves an actual Ioss of substance meaning that the cells normally available for healing wounds are lacking. Tissue devitalization is a distinctive feature of ulcerations. Ulcers can be caused by persistent pressure vascular occlusion or microangiopathy such as is brought on by a diabetic state. Ulcerations require treatment that will optimize the physiological biomechanical pharmacological and cellular responses which can help to close thc defects in question. Capillary basement membrane thickening the hallmark finding of diabetic microangiopathy appears to be the result of insulin deficiency. Microangiopathy makes foot and leg vessels especially vulnerable to thrombosis occlusion and ulceration from internal or external sources of pressure. These types of ulcers can be extremely painful if neuropathy is absent. Ulcer bases granulate poorly and the necrotic slough is often very tenacious. Normally pain is perceived in areas of the foot that are subject to excessive pressure. This leads a person son to shift their weight and thus reduce pressure on the painful area. When neuropathy is present such impulses are not perceived which leads to further pressure being applied on an already traumatized area. Under continued pressure callouses form for protection. Further trauma creates soft tissue breakdown and hemorrhage beneath the callous gradually eroding the overlying keratin layer and thus completing ulcer formation. Again if neuropathy is evident the patient may continue to ambulate normally thereby worsening the status of the ulcer. In diabetics with evidence of both neuropathy and microangiopathy characteristics of both types of ulcer may appear. These are especially dangerous since blood flow is also inadequate. In the absence of treatment to help resist devastating infection ulcerations of the extremities can often lead to The treatment of foot ulcers requires patience on the part of the foot specialist as well as the patient. Aggressive yet cautious therapy must he initiated immediately. Team approaches are often useful especially when other physicians such as peripheral vascular specialists or endocrinologists must be consulted. Consultation with and or referral to another specialist should be prompt in order to ensure that the patient s health is not jeopardized. Some treatments available for diabetic ulcers include iodine preparation soaks hydrophilic beads zinc oxide bandages proteolytic enymes impregnated wound dressings antibiotics and topical or oral gentian violet. It is also important to promote the epitheliaziation of callous tissue. Plantar foot ulcerations are well managed by prescription orthotic devices and custom shoes specially designed to concentrate the body s weight at the heel and thus ease pressure on the forefoot. Prescription orthotics covered with soft materials such as plastizote or poron are also effective in alleviating pressure. Latex shields and over-the-counter polymer gel pads are similarly effective in providing protection by surrounding the ulcerated area in patients suffering the pain 0f bunions or callouses. Kurotex and other felt pads are also successful in protecting the affected site. Material preparations that accommodate and relieve pressure on ulcers are an extremely important component of care and provide along with infection avoidance a first line of defense. Given the proper diagnosis good medical management and aggressive therapy many ulcerations seen by the foot specialist can successfully be resolved. Hartley Miltchin DPM Canadian Footcare Practice April 1995 Vol. 1 No. 1 April 1995 by Hartley Miltchin D.P.M. 4 Foot Health Advice 1993-1995 Heel Pain What Causes It Common Heel Conditions I will restrict the discussion in this issue to the diagnosis of common heel conditions appropriate treatment will be discussed in future issues. Plantar fascitis usually arises after age 30 affects men and women equally and is not specific to increased body weight or particular occupations. The most frequent complaint is extreme pain in one or both heels especially during the first few steps after a rest. The pain is usually insidious and can become more chronic with patients complaining of throbbing throughout the day Pain can be elicited as the digits and foot are dorsiflexed while the practitioner palpates the medial or central plantar aspect of the affected foot. More commonly pain is most extreme at the insertion of the medial band. Numbness and or burning pain are not seen in plantar fascitis. Radiographically subcalcaneal exostosis may be present in conjunction with plantar fascitis. It is not the heel spur which elicits pain in this condition. Tarsal tunnel syndrome is another common condition in the heel which presents with a gradual pain emanating from the posterior aspect of the heel and continuing below the medial malleolus area towards midfoot. The pain is generally described as an ache that is aggravated by continuous weight bearing and becomes less intense when not weight bearing. Paresthesia can in longstanding instances be elicited along the medial plantar area of the heel and foot. Palpation along the course of the posterior tibial nerve just inferior to the medial malleolus can elicit Tinel s sign. This maneuver will cause pain and or paresthesia along the distal course of the nerve especially in the calcaneal branch. At times an electromylogram may be required to help the diagnosis. The cause of this condition is a compression of the posterior tibial nerve beneath the laciniate ligament. Heel neuroma can result from irritation of the calcaneal branch of the posterior tibial nerve. The syndrome is difficult to diagnose and has a similar symptomatology to tarsal tunnel syndrome but the pain does not radiate further than the heel area. Pain on palpation is usually below and posterior to the tarsal tunnel region. Medial heel pain can also be identified with posterior tibial tendon irritation or rupture especially in patients who exhibit pes planovalgus deformity Tenderness is often identified alone the posterior tibial tendon and sometimes rupture can also be palpated. Other causes of heel pain can be a loss of plantar fat which creates a compression shock condition calcaneal fractures (which may only be detectable on scan) rheumatoid arthritis psoriatic arthritis Reiter s syndrome and sinus tarsi faults. Making a diagnosis for heel pain can be perplexing and the practitioner must rely on careful examination and a systematic review of symptoms. Hartley Miltchin DPM Canadian Footcare Practice September 1995 Vol. 1 No. 2 September 1995 by Hartley Miltchin D.P.M. 5 Foot Health Advice 1993-1995 Foot Surgery The Minimal Incision Approach It has now been more than 25 years since Minimal Incision Surgery (MIS) was introduced in the United States and Canada. More and more Canadian podiatrists are learning the skills required to offer their patients an alternative to hospitalization when surgery is indicated to treat a foot disorder. MIS is part of a growing trend in the medical community to adopt surgical procedures that result in less tissue dissection and trauma. Procedures involving the knee spine cranium and abdomen are now frequently accomplished through much smaller openings in the skin. MIS is performed in the podiatrist s office under local anesthetic. A small incision is made in the patient s skin and specially designed instruments are inserted into the opening. These instruments include mini-blades to cut soft tissue chisels to free soft tissue from bony prominences bone to reduce the bony prominences and rotary burrs to both remodel the bone and perform osteotomies. Tourniquets are not necessary. Irrigation is used to flush the small bone particles out through the incision both during and at the conclusion of surgery. The use of intra-operative fluoroscopy allows the practitioner to visualize the osseous structures during the procedure. Podiatric conditions that can be treated with minimal incision surgery. Corns Corns are caused by excessive pressure or friction on the skin. In many cases appropriate shoe wear periodic debridement of the corn and the use of corn pads are sufficiently effective treatments. Recurrent painful corns however are often the result of bone enlargement or a bone spur which pinches the skin against the shoe. Soft corns result when two bony prominences rub against each other and pinch the skin between two toes. MIS is an excellent means of eliminating the corn permanently. Through a small incision made just adjacent to the corn the soft tissue is separated from the bony prominence and the prominence is removed. Often the patient is able to walk out of the office in their own shoe and return to normal activities in a short period of time. Callouses Callouses are a thickening of the skin in an area most often on the ball of the foot exposed to persistent and abnormal friction. Diffuse callouses are frequently the result of abnormal biomechanics and are often treated effectively with ortliotic devices and appropriate shoe gear. Deep-rooted callouses are usually structural in nature often the result of a long or plantar-flexed metatarsal. Periodic debridement of the callous the use of callous pads and accommodative orthotics can help to ease the severity of these lesions. Recurrent painful callouses under one of the metatarsal heads often respond well to minimal incision surgery. A small incision is made on the dorsal aspect of the foot and an osteotomy is made at the neck of the affected metatarsal in order to reposition the metatarsal head more dorsally The underlying condition has been corrected and the patient remains ambulatory with a reduced amount of discomfort and disability. Bunions A bunion (synonymous with a hallux abducto valgus deformity) is a malalignment of the first metatarsal phalangeal joint. The hallux angulates towards the second toe the first metatarsal deviates medially and the medial portion of the first metatarsal head enlarges as a result of shoe pressure with a bursitus often developing. As the deformity progresses arthritis may damage the joint space. The underlying etiology is usually an inherited weakness in the bone structure of the foot. Bunions are not caused by improper shoe gear but are certainly aggravated by them which makes them much more common in women. It is important that the bunion be recognized early and evaluated by a foot specialist. Treatment includes proper footwear and prescription orthotic devices to help control the underlying foot imbalance. Bunion guards can be helpful in reducing the discomfort of a bursitis or preventing inflammation from developing. Undoubtedly the most exciting application of minimal incision surgery is in the treatment of bunions. The hypertrophied medial eminence of the first metatarsal head can be remodelled. Using rotary burrs osteotomies can be performed at the neck of the first metatarsal to reduce 6 Foot Health Advice 1993-1995 an increased first intermetatarsal angle and or at the shaft of the proximal phalanx of the hallux to reduce an increased hallux abductus angle. Soft tissue release of a tight capsule or ligament can also be performed with this technique. The Advantages of MIS The advantages of minimal incision surgery to the patient are many local anesthesia is much safer than general anesthesia and the small incision means less trauma to the tissue and hence faster healing with less postoperative discomfort. The potential for a serious hospitalbased infection is eliminated. Casts crutches and internal fixation are usually unnecessary. The patient walks out of the office and is able to remain ambulatory with minimal disability and a more rapid return to normal activity. In this era of preoccupation with the high costs of health care reduced O.R. time and fewer hospital beds office-based minimal incision surgery allows for better use of hospital facilities while benefiting the patient who is undergoing foot surgery. Neil Naftolin DPM Canadian Footcare Practice September 1995 Vol. 1 No. 2 September 1995 by Neil Naftolin D.P.M. 7