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The subcortical edema may occur from excessive compression forces acting on the trabeculae possibly leading to microfracture of the trabeculae, and the edema may also possibly result from excessive tensile forces acting on the bone leading to excessive tensile damage to the subcortical trabeculae.
Kevin, how do you know there is microfracture of the trabeculae?
Kevin, how do you know there is microfracture of the trabeculae?
Cheer
Frederick
Frederick:
I don't know for sure if the bone edema seen in traumatic injuries is always caused by microfracture of the trabeculae. However, it certainly seems that fracture of the trabeculae, either by abnormal compression, tension or shearing stresses is most logical cause of what we now call "bone edema" based on the available research and known microscopic anatomy, biomechanics and pathophysiology of bone in response to abnormal stresses.
Here is an excellent book which includes an excellent discussion on the microphysiology of bone which I highly recommend by Neil Sharkey and coworkers:
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Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
The subcortical edema may occur from excessive compression forces acting on the trabeculae possibly leading to microfracture of the trabeculae, and the edema may also possibly result from excessive tensile forces acting on the bone leading to excessive tensile damage to the subcortical trabeculae.
Kevin Kirby
Kevin, how do you know there is "microfracture of the trabeculae?"
Kevin, even though this may seem theoretically logical to you, and keeping to the clinical point, I mostly see symptomatic bone marrow oedema where there is long standing heel spur/plantar fasciitis. These patients often have also developed compensatory achilles tendonitis, so they aren't doing a lot of heel contact.
I think in these cases the inflammation, because that is what the bone marrow oedema illustrates, could be caused by the rupturing of the plantar fascia attachment, Sharpey's fibres etc.
Certainly one could have traumatic internal fractures, akin to a stress fracture, that would also cause bone marrow oedema.
I also think, for want of a better diagnosis (guessing is not better), bone marrow oedema is adequate when that's all we have. We certainly use "heel spur" and "hallux valgus" as diagnoses, symptomatic or not, and these are just xray findings.
Manmantis would you consider ordering an MRI for your patient? If the scan was positive for bone marrow oedema (due to an underlying microtrabecular fracture) would it change your management?
Apologies for not following this up.
In answer to your question Nick, I discussed the options of MRI and indeed a bone scan with some Radiographer colleagues. We haven't had direct referral access to MRI as Podiatrists locally but I have negotiated such. The only problem is that the nearest scanner is a 2 hour drive away and MRI does not attract any Medicare rebate. So my patient/friend has a 2 hour drive & $250 to consider. A bone scan can be done locally, the question is would it tell me anything useful?
Would either of these investigations change my treatment plan? Probably not, but it would be nice to see the "diagnosis" confirmed.
My treatment thus far has focused on off-loading/cushioning the calcaneus. That line of treatment has been to date reasonably effective. I have advised him that if the pain continues then we really need to consider the use of a Cam-walker or similar to fully off-load his heel(s). He now gets good days, then does something high impact & it then hurts for a few days after. Lets call the scenario "managed discomfort", he's quite reluctant to go to the next level of therapy.
Thanks for the follow up manmantis. I am in Melbourne and whilst MRI is more easily accessible, the prohibitive cost is indeed an issue (>$275). The poor specificity of a bone scan may let you down. It will tell you something is happening but not necessarily what that something is (i.e. tumour/fracture/infection etc...)
In answer to your question Nick, I discussed the options of MRI and indeed a bone scan with some Radiographer colleagues. We haven't had direct referral access to MRI as Podiatrists locally but I have negotiated such. The only problem is that the nearest scanner is a 2 hour drive away and MRI does not attract any Medicare rebate. So my patient/friend has a 2 hour drive & $250 to consider. A bone scan can be done locally, the question is would it tell me anything useful?
Would either of these investigations change my treatment plan? Probably not, but it would be nice to see the "diagnosis" confirmed.
My treatment thus far has focused on off-loading/cushioning the calcaneus. That line of treatment has been to date reasonably effective. I have advised him that if the pain continues then we really need to consider the use of a Cam-walker or similar to fully off-load his heel(s). He now gets good days, then does something high impact & it then hurts for a few days after. Lets call the scenario "managed discomfort", he's quite reluctant to go to the next level of therapy.
Cheers for the advice so far.
and that's a good reason not to treat family and friends
Manmantis obviously lives in an area that has limited options for medical imaging, based on the fact the patient needs to drive 2 hours for an MRI. Therefore there may also be limited options for treatment by another podiatrist i.e. a semi-rural area. That situation is not unusual in various parts of Australia.
Whilst treating family and friends can get tricky from a financial perspective (I've been burned before!), Manmantis' friend may not have another option. And also, how do you go about telling somebody "Yes I am a podiatrist, yes I could help you, but no I won't help you. Drive 2 hours to the closest major centre and seek help from one of my colleagues who I have no direct relationship to and may not have the same knowledge/skill set that I do"
But you make a good point. Treating family and friends is way too hard and I cringe whenever I get a text/email asking for my clinic phone number
and that's a good reason not to treat family and friends
On the other hand, when my mother-in-law, who I love dearly, asked me about her bunion and if I could fix it for her, I told her that I would have no problem doing the surgery to correct it for her. I couldn't bear it if someone else had done a poor job on her surgery, and she ended up with more pain after surgery than before surgery, when I knew I could do a good job on it for her. It all depends on what you and the relative feels comfortable with.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
On the other hand, when my mother-in-law, who I love dearly, asked me about her bunion and if I could fix it for her, I told her that I would have no problem doing the surgery to correct it for her. I couldn't bear it if someone else had done a poor job on her surgery, and she ended up with more pain after surgery than before surgery, when I knew I could do a good job on it for her. It all depends on what you and the relative feels comfortable with.
Exactly. Imagine if you had said "sure mother of my wife, I could fix your bunion but I would prefer not to, instead see somebody else who may or may not stuff it up. That way my conscience will be clear"
It all depends on what you and the relative feels comfortable with.
As I explained to the students during the week, family and friends are the worse types of patients .... right up there with elite athletes! ... avoid them.
__________________ Craig Payne
__________________________________________________ ___________________________________ Follow me on Twitter | Run Junkie God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
Exactly. Imagine if you had said "sure mother of my wife, I could fix your bunion but I would prefer not to, instead see somebody else who may or may not stuff it up. That way my conscience will be clear"
Hmmm....
Image if you did stuff it up Christmas and other family gatherings be fun.
But it comes back to the people involved, Podiatrist and Patient/family member.
All this guessing about "microtrabecular fractures" or pedantic debating about "syndrome" isn't helping your patient.
If you cannot control your patient well enough with orthotics, try a corticosteroid injection (heel spur area) to reduce the inflammation in the area. It should work, and if the orthotics are effective, and reduce the overuse enough, the heel may remain asymptomatic.
And of course, make sure you aren't getting a Baxter's nerve pain when your are compressing the calcaneus.
Otherwise, surgery including calcaneal decompression might be his only answer.
All this guessing about "microtrabecular fractures" or pedantic debating about "syndrome" isn't helping your patient.
If you cannot control your patient well enough with orthotics, try a corticosteroid injection (heel spur area) to reduce the inflammation in the area. It should work, and if the orthotics are effective, and reduce the overuse enough, the heel may remain asymptomatic.
And of course, make sure you aren't getting a Baxter's nerve pain when your are compressing the calcaneus.
Otherwise, surgery including calcaneal decompression might be his only answer.
Re: Forefoot Equinus...and calcaneal pain.
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