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Calcaneal Bone Marrow Edema/microfracture of plantar calcaneus Patient discussion

Discussion in 'Biomechanics, Sports and Foot orthoses' started by mike weber, Nov 1, 2011.


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    The other month were discussing this condition ...

    Here is some Highlights

    Anyways had a patient come in the other day with long standing heel pain.

    Started 9 years ago focused in the area of the medial plantar calc.

    Was diagnosed as a Heel Spur by a local Sports Med Dr - treatment has included, Acupuncture, EVA full length insoles with met dome, Shock wave treatment, Soft heel spur pads, Cortisone injections * 2 all of which have not helped and the pain id slowly getting worse and more diffuse.

    The patient has has 3 MRI which have come back as unremarkable except the last one in Feb 2011 -

    - Insignificant change in the Plantar Fascia
    - Some changes but minimal edema subcutaneous at the insertion of the plantar fascia but not significant for Plantar fasciitis
    -no heel spur or significant edema at the insertion of the plantar fascia

    But he is in significant pain on every step and has stopped all activities and now the pain is in the whole calcaneal area.

    I performed the squeeze test Fredrik wrote about the the patient hit the roof - so made a preliminary diagnosis of Calcaneal Bone Marrow Edema/microfracture of plantar calcaneus.

    I have some MRI picture which I will try and load up - Can anyone help make a better diagnosis ?

    What would be the steps in treatment for a patient with Calcaneal Bone Marrow Edema/microfracture of plantar calcaneus who has been in pain for 9 years ?
     
  2. A Couple of MRI picture not the best quality and can upload more if required
     

    Attached Files:

  3. Nothing

    Zip

    Nadda

    Well I guess I will expand some patient info a little which should not make a different as we have the MRI report.

    Male 35

    9 yr history of right heel pain.

    Pain started as classic medial band plantar fascia issues ( call it what you will) pain mainly at the insertion to the Calc.

    - Morning pain
    - increased pain after activity

    Was diagnosed as a Heel Spur by a local Sports Med Dr - treatment has included, Acupuncture, EVA full length insoles with met dome, Shock wave treatment, Soft heel spur pads, Cortisone injections * 2 all of which have not helped and the pain id slowly getting worse and more diffuse.

    The patient has has 3 MRI which have come back as unremarkable except the last one in Feb 2011 -

    - Insignificant change in the Plantar Fascia
    - Some changes but minimal edema subcutaneous at the insertion of the plantar fascia but not significant for Plantar fasciitis
    -no heel spur or significant edema at the insertion of the plantar fascia

    But he is in significant pain on every step and has stopped all activities and now the pain is in the whole calcaneal area.

    I performed the squeeze test Fredrik wrote about the the patient hit the roof - so made a preliminary diagnosis of Calcaneal Bone Marrow Edema/microfracture of plantar calcaneus.

    Biomechancial assessment highlights

    Moderately Medial deviated Subtalar joint axis

    Slightly increased Subtalar joint supination resistance

    Increased dorsiflexion stiffness @ 1st and Talocural

    But in reality all of this not so important as we have a patient with diffuse Calcaneal pain on every step and a relatively unremarkable MRI.

    At this stage I´m considering non-weightbearing on the right side ie crutches for 3 weeks to see if the pain reduces any one got any better suggestions and if that is unsuccessful what would be the next step ?

    Refer to a surgeon for a consult for decompression surgery ?
     
  4. blinda

    blinda MVP

    What was the outcome for this pt, Mike? Got one with similar hx in sunny Winchester.
     
  5. Nothing - Patient did not want to rest and when I suggested a walker boot I may as well have told him his life was over.

    But I would go with walker 6-8 weeks

    Device which reduces both tension and Compression forces acting on the plantar fascia

    Rehab/hands on stuff for the Gastroc and Soleus

    Slow return to weight bearing activities

    Shoot me an email if I can be of any assistance - idea bouncing etc etc

    Nice to be back at work ?
     
  6. blinda

    blinda MVP

  7. RobinP

    RobinP Well-Known Member

    Interestingly, since Frederick posted that answer to my question some time ago, I have been looking out for this more.

    Essentially, the way I see it is

    1. There probably has been some major excessive plantar fascia tension and compression forces that have been part of the acute injury.

    2.Left untreated or having had insufficient treatment of the aforementioned, the bone marrow oedema has developed.

    3. With the treatment modalities improved and/or redcued activity levels, the original plantar fascia issue becomes secondary to the bone marrow oedema.

    4. Any compression of the heel, even normal walking, is enough to cause increased inflammation/bone marrow oedema despite any amount of offloading

    I have had a couple where I really need to give a lot of cushioning at the heel and others where a walker has been required. The walker very quickly reduced the pain and within a few weeks, the same heel squeeze test was significantly improved.

    Totally anecdotal and n=a few but as you ain't had much from anyone else, I thought I would chip in my limited experience

    Robin
     
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