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i recently ran across an article regarding what is termed as a decompression osteotomy of the heel in order to eliminate diffuse heel pain.whose etiology has been deemed not due to tarsal or sinus tarsi syndrome or heelspur syndrome.it consists of drilling a series of holes with a .062 k-wire in the medial central aspect of the calcaneus.the holes form a circle.the authors describe it as a diffusing of inflammation.is anyone familiar with this and its mechanism of efficacy,if there is any.
I am not familiar with the technique, but I do recal recently seeing the same publication you mentioned. I also have another one on file somewhere from the Chinese Medical Journal describing the same technique.
What intrigues me about this, is that there was a study in AJR a while back that did some detailed MRI's of insertional plantar facisiitis/heel spur syndrome - I can not remember the numbers but many of them had bone marrow oedema .... that suggests to me that we a dealing with different subpopulation of what we thought might have had insertional plantar fasciitis - ie what role does the bone marrow oedema play Does it have anything to do with ESWT or the above technique of drilling holes in the calcaneus (relieveing the oedema )
__________________ Craig Payne
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The authors report a retrospective study involving 25 feet in 21 patients who underwent percutaneous drilling for chronic heel pain. Patients with increased activity of the heel were considered for surgical treatment if there was increased uptake on the delayed bone scans. The average follow-up was 21 months (range, 6 to 30 months). All patients were treated in day surgery with local anesthesia. Three small holes were bored in the medial cortex of the calcaneus. Clinical evaluation of the parameters of pain, walking distance, fascial tenderness, paresthesias, and ankle and subtalar joint motion were evaluated preoperatively and at final follow-up. In 7 patients, repeat bone scans were performed and 6 patients had resolution of the abnormal uptake. In 81% of feet treated, there was a favorable outcome based on a subjective scoring scale. Using a visual analog pain scale, the preoperative pain level was 8.8 (range, 4 to 10), and at latest follow-up, it was 2.4 (range, 0 to 10). These results are comparable to other available surgical methods for the treatment of recalcitrant heel pain. Less predictable results were seen in patients with rheumatic and systemic pathologies and in those diagnosed with Haglund deformity. This technique appears to be effective in the relief of intraosseous congestion and bone-marrow edema.
OBJECTIVE: To clarify morphologic features associated with the clinical outcome of extracorporeal shock wave application (ESWA) in chronic plantar fasciitis. METHODS: In this prospective study 43 patients (48 heels) with chronic courses of plantar fasciitis were clinically examined before and after repetitive low energy ESWA. Standard radiographs of the affected heels were obtained before ESWA to document the existence of a calcaneal heel spur. Magnetic resonance imaging (MRI) was performed before ESWA to evaluate abnormalities of the plantar fascia, the surrounding soft tissue structures, and bone marrow edema of the calcaneus. RESULTS: After ESWA (mean followup 19.3 mo), clinical evaluation of all 48 heels revealed a statistically significant decrease in the mean visual analog scale score from 74.5 to 25.4. Using the Roles and Maudsley score (RM), an established scoring system for categorizing results of treatment following ESWA for patients with plantar fasciitis, patients could be divided into 2 groups, i.e., satisfactory clinical outcome of ESWA (grades 1 and 2 by RM scale; n = 36 heels) and unsatisfactory outcome (grades 3 and 4 by RM scale; n = 12 heels). While thickness of plantar aponeurosis, soft tissue signal intensity changes, and soft tissue contrast medium uptake did not correlate with clinical outcome, the presence of a calcaneal bone marrow edema was highly predictive for satisfactory clinical outcome (positive predictive value 0.94, sensitivity 0.89, specificity 0.8). CONCLUSION: This study indicates that in patients with chronic plantar fasciitis, the presence of calcaneal bone marrow edema on pretherapeutic MRI is a good predictive variable for a satisfactory clinical outcome of ESWA
We sought to evaluate various MR imaging signs of plantar fasciitis and to determine if a difference in these findings exists between clinically typical and atypical patients with chronic symptoms resistant to conservative treatment. CONCLUSION: We found signs on MR imaging that, to our knowledge, have not been described in the scientific literature for patients with plantar fasciitis. These signs included occult marrow edema and fascial tears. Patients with these manifestations seemed to respond to treatment in a manner similar to that of patients in whom MR imaging revealed more benign findings.
Last edited by Admin : 20th November 2004 at 04:06 PM.
i am very grateful to the host for the references on the subject.however,i agree with craig,as to what exactly is the role of bone marrow edema in plantar fasciatus or diffuse heel pain for that matter?
would one first evaluate the role of bone marrow edema of the calcaneus through a bone scan,both pre and post operatively?
finally,does anyone have specifics on the technique itself?
I work with two Physiotherapists who are both advanced traditional Chinese and, also, Western Accupuncturists. They have a technique for heel pain which involves 'peppering' the periosteum of the calcaneus with accupuncture needles. This also elicits an inflammatory response and apparently promotes healing and, therofore, pain-relief, in the same way as 'hitting it with a hammer' (see ECSWT thread on General Forum) and actual osteal drilling.
It is, as you can imagine, extremely painful to 'pepper' in this way and I have recently been carrying-out a tibial nerve block prior to 'needling'. Results are to be awaited, but, obviously, this technique has the advantage of being able to be performed in a clinical room, with little, or no, post-op infection risk.
Phyisos will also use a technique called myofascial release, with some success.
i am curious,when you were describing the acupuncture technique in your memo.you mentioned that they place the needles to the level of the periostium.so are they basically taking it to the level of the bone?
you also mentioned myofascial release,now are talking about release of plantar fascia via some kind of cross frictional therapy or do you mean actual fasciotomy procedure.
in a way this is very similar to prolotherapy whereby you create injury in order to promote healing via inflammation(i am oversimplifying of course).
i look forward to your thoughts on the matter.