Etiology and treatment of heel pain

Heel pain is caused by a series of diseases of heel pain syndrome. According to the location of the heel pain can be divided into heel pain


Heel pain is caused by a series of diseases of heel pain syndrome. According to the location of the heel pain can be divided into heel pain and heel pain. The former often due to plantar fasciitis, plantar fascia fracture, with fat pad inflammation, the first branch of the lateral plantar nerve entrapment, calcaneal spur, calcaneal periostitis, calcaneal fractures caused by. The latter is often caused by Achilles bursitis, tendonitis. While tendonitis can be divided into non stopping point of Achilles tendinitis and stopping point of Achilles tendinitis two. In children, with back pain in the calcaneal tubercle physitis. Some systemic diseases, such as rheumatoid arthritis, gouty arthritis, Reiter syndrome, ankylosing spondylitis, can also cause heel pain. Calcaneal hypertension is thought to be a cause of heel pain. Calcaneal drilling decompression is seldom used to treat heel pain.

Beijing Tongren Hospital orthopedic Zhang Jianzhong

The proximal plantar fasciitis

(I) anatomical characteristics

The plantar fascia is a shallow part of the plantar fascia, and similar palm aponeurosis, but more developed and tenacity, consisting of white fiber longitudinal. The medial, lateral and medial bundle. The middle beam thickness, since the medial tubercle of the calcaneus forward divided into five beams, respectively, to Gezhi toe joint plantar skin, flexor tendon and tendon sheath fiber. Since the medial tubercle of the calcaneus foot intrinsic muscle and abductor pollicis brevis, abductor digiti minimi and plantar muscle. The effect of plantar fascia (1) foot protection organization. (2) provide the attachment points of certain intrinsic muscles of the foot. (3) to assist in the maintenance of the arch.

(two) etiology and pathology

The exact cause of proximal plantar fasciitis occurs is not clear. May cause pain caused by: 1, walking, dorsiflexion of metatarsophalangeal joints, pulling the plantar fascia to stretch the calcaneal tuberosity. With the increase of age, foot muscle, ligament weakened, plantar fascia stretching the calcaneal tuberosity strength increases, long-term and repeated stretch the plantar fascia starting point part of the micro tears, secondary inflammation, pain. 2, the fatigue fracture of calcaneus plantar fascia insertion point of the medial calcaneal tubercle and periostitis. 3, flexor digitorum brevis insertion of inflammation and edema and hyperplasia of the bone in the first branch of the lateral plantar nerve nerve entrapment. Although the proximal plantar fasciitis as a diagnosis, but in fact, the plantar fascia proximal part of the anti inflammation, the first branch of the lateral plantar nerve nerve entrapment may exist at the same time, it is difficult to distinguish clinically.

Clinical found more obese middle-aged women who love sports and plantar fascia, such as professional athletes and dancers long time running and jumping and walking for a long distance the needs of ordinary people. May also wear soft shoes and excessive exercise is one of the reasons for plantar fasciitis. Some other cases, such as tibial varus, valgus calcaneus, contracture of Achilles tendon, foot pronation deformity, in the elderly, foot tendon and ligament degeneration after the arch changes, will enable the plantar fascia withstand greater stress, chronic traction can make local aponeurosis tiny tear, local edema and inflammation. Berkowitz MRI by comparing the normal and chronic pain patients with proximal plantar fascia thickness, the latter found increased 4.4mm than the former. The proximal plantar fascia pathological examination also found that collagen fiber necrosis, vascular hyperplasia, cartilage metaplasia and matrix calcification. This is similar to the pathological changes of patients with tennis elbow radial extensor carpi radialis brevis insertion point of change, and one proximal plantar fasciitis as "tennis with".

Many patients with proximal plantar fasciitis can be found to have calcaneal spur. DuVries thought is the main reason with calcaneal spur plantar medial pain. Tanz in 1963 compared with pain and normal human lateral X ray showed that the former calcaneal spur was 50%, while the latter is only 16%. Rubin and Witton believe that only 10% of the calcaneal spur will cause heel pain. The study also found that the starting point is located at the calcaneus heel spur of plantar fascia, but in the deep plantar flexor digitorum brevis muscle of the calcaneus at the starting point. In addition to a small number of patients, the most proximal plantar fasciitis patients without resection of bone.

(three) clinical manifestations

Plantar metatarsal pain. Slow onset. In the first few steps in the morning when the pain is more severe, the pain can be partially alleviated after further activity. However, after a long period of time and can aggravate symptoms.

Check the visible heel medial swelling. There was tenderness nodules and the medial plantar fascia starting point 2~3 cm. Pay attention to patients without foot malalignment, no tibial varus, strephenopodia and pingzu, high arch foot, you should also check whether the contracture of Achilles tendon.

X-ray examination: about 50% of patients with plantar calcaneal spur visible. Ultrasound and MRI examination showed the plantar fascia thickening and edema.

At the time of diagnosis according to local pain, tenderness point. Ultrasound and MRI that is helpful to the diagnosis of plantar fascia thickening.

(four) treatment

1, non-surgical treatment

More than 90% of patients with non-surgical treatment is effective, but because of the treatment, can not determine what kind of treatment has a certain effect, often need several methods combined with the use of comprehensive treatment. In some patients even without treatment, the pain can be relieved. But some patients have pain for several years.

(1) to reduce the impact of the collision with the impact. Weight loss in obese patients.

(2) the Achilles tendon, the plantar fascia stretching exercise. The Achilles tendon is a common cause of plantar fasciitis, plantar fascia and the moderate stretch contributes to inflammation. Repeated every day Achilles plantar fascia stretch exercise to reduce pain in patients with plantar fasciitis has become one of the most effective methods. The aim is to report that the efficiency is 83%. After getting up every day, you should exercise before walking. Exercise 4 to 5 times a day, each time from 5 to 10 times, after 1 ~ 2 months can achieve significant results.

Plantar fascia stretching exercise method: patients sitting, knees, the ipsilateral heel in bed, ankle dorsiflexion, hand 5 toe dorsal push, hold for 30 seconds, repeated 5 times. The heel lift, buttocks sitting on the heel, and hold for 30 seconds, repeated 5 times. The patient seat, ipsilateral heel lift, the metatarsophalangeal joint dorsal flexion as far as possible by hand, pushed down the calf, further increase the pulling force of plantar fascia, hold for 30 seconds, repeated 5 times. The ipsilateral foot below the front wall, and forced plantar flexion of ankle joint, hold for 30 seconds, repeated 5 times.

Achilles tendon traction exercise: soleus muscle pulling exercise, the patient to the wall to stand, after suffering from the side, slowly bend the knee to the flexion position, maintain 30 seconds, repeated for 5 times. The gastrocnemius muscle stretching exercise, patients to stand in the side wall, and keep the lower limb and foot straight, do not move, the heel can not lift the upper body to move forward, to stretch the Achilles tendon. For 30 seconds, repeated for 5 times. Achilles tendon traction exercise, standing on the inclined panel, the body upright, so that the Achilles tendon is pulled.

(3) physiotherapy. Such as ultrasound, electrical stimulation, cold and hot treatment. But the general effect is not obvious.

(4) to correct the bad foot line. Such as the use of foot pad, high arch foot semi hard adaptive foot pads, foot pad support use flatfoot slightly hard, reduce the plantar fascia stretching. The use of pad can reduce the impact force of calcaneus heel, to relieve pain.

(5) anti-inflammatory analgesic drugs. Local closure.

(6) more pain, available at night splint or plaster fixation of ankle dorsiflexion 5 degrees to 10 degrees, so that in the night of plantar fascia contracture, the morning pain caused by activities.

(6) of the patients with severe pain plaster fixation, treatment failure, available short plaster fixation ankle joint in neutral position in January.

(7) extracorporeal shock wave therapy

Extracorporeal shock wave therapy early treatment of renal calculi. In 90s, extracorporeal shock wave has been widely used in the field of Department of orthopedics. For the treatment of nonunion and delayed healing and some chronic pain disorders such as tennis elbow, shoulder, plantar fasciitis. Mechanism of shock waves on the human body is not very clear. Strash believes the mechanism of shock wave therapy for plantar fasciitis is a shock wave can promote tendon and bone junction neovascularization, increase local blood circulation, accelerate the extinction of local inflammation.

Ogden analysis of 302 cases of plantar fasciitis patients treated by ESWT according to the randomized double blind principle, after 3 months of treatment in accordance with the 4 standard 1 evaluation, subjective feeling of pain and improvement of at least 50%, VAS pain score below 4. 2, at least 50% improvement in pain when walking early in the morning, VAS pain score of less than 4. 3, painless walking time and distance, basically painless or at 5 points in the score to improve more than 1 points. 4, do not need analgesics after treatment. After ESWT treatment can meet the 4 criteria of patients accounted for 56%.

The use of extracorporeal shock wave therapy in 98 cases of plantar fasciitis patients, efficiency was 80%. However, the effective rate of the 1 treatment was lower, and the curative effect was obviously improved after the 3 treatment.

2, surgical treatment

A very small number of patients after 6 months of non surgical treatment ineffective, can be treated with surgery. The plantar fascia plays an important role in maintaining the arch, completely cut off the plantar fascia may have adverse effects on the function of the foot. The study shows that, completely cut off the plantar fascia can cause patients unable to walk side, and 25% less power arch stability. At present, the operation method is recommended by the plantar fascia partial amputation, from the plantar fascia insertion of medial cut 35% ~ 50%. You can also remove or not removing the medial calcaneal tubercle. Open or percutaneous surgery can be completed, if the conditions can also be accomplished by arthroscopy of plantar fascia partial amputation and bone resection.

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