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ABSTRACT: Joint and soft tissue injection of the ankle and foot region is a useful diagnostic and therapeutic tool for the family physician. This article reviews the injection procedure for the plantar fascia, ankle joint, tarsal tunnel, interdigital space, and first metatarsophalangeal joint. Indications for plantar fascia injection include degeneration secondary to repetitive use and traumatic injuries that are unresponsive to conservative treatment. Diagnostic aspiration or therapeutic injection of the ankle or first metatarsophalangeal joints can be performed for management of advanced osteoarthritis, rheumatoid arthritis, and other inflammatory arthritides such as gout, or synovitis or an arthrosis such as "turf toe." Persistent pain and disability resulting from tarsal tunnel syndrome, an analog of carpal tunnel syndrome of the wrist respond to local injection therapy. A painful interdigital space, such as that occurring in patients with Morton's neuroma, is commonly relieved with corticosteroid injection. The proper technique, choice and quantity of pharmaceuticals, and appropriate follow-up are essential for effective outcomes.
Diagnosing Heel Pain in Adults - Article
ABSTRACT: Heel pain is a common condition in adults that may cause significant discomfort and disability. A variety of soft tissue, osseous, and systemic disorders can cause heel pain. Narrowing the differential diagnosis begins with a history and physical examination of the lower extremity to pinpoint the anatomic origin of the heel pain. The most common cause of heel pain in adults is plantar fasciitis. Patients with plantar fasciitis report increased heel pain with their first steps in the morning or when they stand up after prolonged sitting. Tenderness at the calcaneal tuberosity usually is apparent on examination and is increased with passive dorsiflexion of the toes. Tendonitis also may cause heel pain. Achilles tendonitis is associated with posterior heel pain. Bursae adjacent to the Achilles tendon insertion may become inflamed and cause pain. Calcaneal stress fractures are more likely to occur in athletes who participate in sports that require running and jumping. Patients with plantar heel pain accompanied by tingling, burning, or numbness may have tarsal tunnel syndrome. Heel pad atrophy may present with diffuse plantar heel pain, especially in patients who are older and obese. Less common causes of heel pain, which should be considered when symptoms are prolonged or unexplained, include osteomyelitis, bony abnormalities (such as calcaneal stress fracture), or tumor. Heel pain rarely is a presenting symptom in patients with systemic illnesses, but the latter may be a factor in persons with bilateral heel pain, pain in other joints, or known inflammatory arthritis conditions.
ABSTRACT: Plantar fasciitis causes heel pain in active as well as sedentary adults of all ages. The condition is more likely to occur in persons who are obese or in those who are on their feet most of the day. A diagnosis of plantar fasciitis is based on the patient's history and physical findings. The accuracy of radiologic studies in diagnosing plantar heel pain is unknown. Most interventions used to manage plantar fasciitis have not been studied adequately; however, shoe inserts, stretching exercises, steroid injection, and custom-made night splints may be beneficial. Extracorporeal shock wave therapy may effectively treat runners with chronic heel pain but is ineffective in other patients. Limited evidence suggests that casting or surgery may be beneficial when conservative measures fail.
ABSTRACT: Plantar fasciitis, a self-limiting condition, is a common cause of heel pain in adults. It affects more than 1 million persons per year, and two-thirds of patients with plantar fasciitis will seek care from their family physician. Plantar fasciitis affects sedentary and athletic populations. Obesity, excessive foot pronation, excessive running, and prolonged standing are risk factors for developing plantar fasciitis. Diagnosis is primarily based on history and physical examination. Patients may present with heel pain with their first steps in the morning or after prolonged sitting, and sharp pain with palpation of the medial plantar calcaneal region. Discomfort in the proximal plantar fascia can be elicited by passive ankle/first toe dorsiflexion. Diagnostic imaging is rarely needed for the initial diagnosis of plantar fasciitis. Use of ultrasonography and magnetic resonance imaging is reserved for recalcitrant cases or to rule out other heel pathology; findings of increased plantar fascia thickness and abnormal tissue signal the diagnosis of plantar fasciitis. Conservative treatments help with the disabling pain. Initially, patient-directed treatments consisting of rest, activity modification, ice massage, oral analgesics, and stretching techniques can be tried for several weeks. If heel pain persists, then physician-prescribed treatments such as physical therapy modalities, foot orthotics, night splinting, and corticosteroid injections should be considered. Ninety percent of patients will improve with these conservative techniques. Patients with chronic recalcitrant plantar fasciitis lasting six months or longer can consider extracorporeal shock wave therapy or plantar fasciotomy.
Diagnosis of Heel Pain - Article
ABSTRACT: Heel pain is a common presenting symptom in ambulatory clinics. There are many causes, but a mechanical etiology is most common. Location of pain can be a guide to the proper diagnosis. The most common diagnosis is plantar fasciitis, a condition that leads to medial plantar heel pain, especially with the first weight-bearing steps in the morning and after long periods of rest. Other causes of plantar heel pain include calcaneal stress fracture (progressively worsening pain following an increase in activity level or change to a harder walking surface), nerve entrapment (pain accompanied by burning, tingling, or numbness), heel pad syndrome (deep, bruise-like pain in the middle of the heel), neuromas, and plantar warts. Achilles tendinopathy is a common condition that causes posterior heel pain. Other tendinopathies demonstrate pain localized to the insertion site of the affected tendon. Posterior heel pain can also be attributed to a Haglund deformity, a prominence of the calcaneus that may cause bursa inflammation between the calcaneus and Achilles tendon, or to Sever disease, a calcaneal apophysitis in children. Medial midfoot heel pain, particularly with continued weight bearing, may be due to tarsal tunnel syndrome, which is caused by compression of the posterior tibial nerve as it courses through the flexor retinaculum, medial calcaneus, posterior talus, and medial malleolus. Sinus tarsi syndrome occurs in the space between the calcaneus, talus, and talocalcaneonavicular and subtalar joints. The syndrome manifests as lateral midfoot heel pain. Differentiating among causes of heel pain can be accomplished through a patient history and physical examination, with appropriate imaging studies, if indicated.