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I have a patient with heel pain that hasn't responded to the usual first line treatments. His pain is reproduced the most when he inverts and plantarflexes his foot.
I have been reading up on heel pain differential diagnosis and have come across Phalen's test. Apparently inversion and plantarflexion increases pressure within the porta pedis and therefore on the nerve. A positive Phalen's sign (numbness or pain) indicates nerve compression syndrome for the posterior tibial nerve or any of its branches.
My main reason for posting is to get a gauge as to whether this inversion / plantarflexion manoeuvre causing heel pain is commonly encountered.
Please could you give a bit more info about this case....
What 'first line' treatments have you tried already?
Is the pain reproduced by inversion/plantarflexion neuro-type pain? ie. does he actually get numbness/pins and needles etc?
Is the pain reproduced on active or passive inversion/plantarflexion?
What makes you think it is nerve related, as opposed to a posterior tibial tendon issue for example?
The patient reproduces his sharp shooting pain with active unresisted inversion and plantarflexion.
Palpation just anterior to the plantar medial calcaneal tubercle elicits pain also.
This 60 year old man has had heel pain for three years. He has a hallux rigidus so I'm limited with what I can do to facilitate the windlass mechanism but have tried temporary measures to reduce excessive pronation and arch flattening with no success. Calf stretches and night splints helped only a little. Cortisone injection (some time ago now) and NSAIDS have not helped.
Without going into more detail, I just wondered about this Phalen's test (more commonly performed at the wrist) as I have not considered it before.
The patient reproduces his sharp shooting pain with active unresisted inversion and plantarflexion.
Palpation just anterior to the plantar medial calcaneal tubercle elicits pain also.
This 60 year old man has had heel pain for three years. He has a hallux rigidus so I'm limited with what I can do to facilitate the windlass mechanism but have tried temporary measures to reduce excessive pronation and arch flattening with no success. Calf stretches and night splints helped only a little. Cortisone injection (some time ago now) and NSAIDS have not helped.
Without going into more detail, I just wondered about this Phalen's test (more commonly performed at the wrist) as I have not considered it before.
Thanks for your interest.
Rebecca
Don't know much about Phalens test. Have you performed a Tinels test? Also check for trigger points in soleus as these can refer to this region.
BTW, funky spelling of (a)etiology
Tinel's is negative. Soleus, quadratus plantae and abductor hallucis trigger points are negative also.
I am only now getting xrays and diagnostic ultrasound done (this patient has been a bit hit and miss with keeping appointments over the course of his heel pain years but has promised to see this through now as its giving him so much trouble). I would like some advice on how specific to be on the ultrasound imaging referral form. As well as plantar fascia thickness at calcaneal attachment, can I ask for details specific to the posterior tibial nerve, the medial and lateral plantar nerves, the medial calcaneal nerve and the first branch of the lateral plantar nerve. Can the Ultrasonographer be expected to know these nerves, visualise them with ultrasound and follow their course to find any abnormalities. Or should I be asking for more general information like 'soft tissue masses medial and plantar calcaneus'.
Chronic heel pain due to the entrapment of the first branch of the lateral plantar nerve: analysis of surgical treatment Journal European Journal of Orthopaedic Surgery & Traumatology Mohammad Mesmar, Zouhair Amarin , Nawaf Shatnawi and Khaldoon Bashaireh
Quote:
This is a case series study that was conducted to report the outcome of surgical release of the first branch of the lateral plantar nerve in patients with chronic heel pain. Thirty-one patients with chronic heel pain underwent release of the first branch of the lateral plantar nerve. The setting was a public university hospital and a public university-affiliated hospital in the north of Jordan. Six patients were lost to follow-up. The average age of the remaining 25 patients was 43.8 years. The average duration of symptoms prior to surgery was 15 months. Radiography showed spur in 14 cases. All patients had conservative treatment for a minimum of 6 months before surgery, and all had one or two local cortisone injection. The average length for recovery was 3 months. All patients, except for 2, reported fair to excellent results. Level of post-operative satisfaction between fair and excellent was reported by 75% at 3 months, 96% at 6 months and 80% at 3–11 years (average 8 years). The diagnosis of entrapment of the first branch of the lateral plantar nerve can be clinical and could be confirmed by nerve block. Heel spurs should be removed when in very close proximity relation to the first branch of the lateral plantar nerve.
A 12-Year Long-Term Retrospective Analysis of the Use of Radiofrequency Nerve Ablation for the Treatment of Neurogenic Heel Pain.
Cozzarelli J, Sollitto RJ, Thapar J, Caponigro J. Foot Ankle Spec. 2010 Sep 3. [Epub ahead of print]
Quote:
The authors discuss their rationale for the use of radiofrequency nerve ablation (RFNA) in the treatment of chronic neurogenic heel pain. Patients treated for plantar fasciitis who fail to improve after conservative and/or surgical treatment should be reevaluated for a coexistent nerve entrapment. The results of a retrospective study of 82 patients who have undergone RFNA are presented. The patients were followed at 5, 10, and12 years after the procedure. An evaluation of medical records was performed as a means of inclusion in this study. A standardized telephone interview was then done, and subjectively scored responses of the patients were recorded and analyzed. Of the patients, 89% reported no recurrence of pain after 5, 10, and 12 years postoperatively. The procedure is relatively easy to perform and involves inserting a 22-gauge cannula with an electrode into the areas of pain. This is done under general anesthesia. It takes approximately 15 to 20 minutes per heel to perform, depending on how many sites of tenderness have been identified. The patient is discharged with a minimal bandage and returns to shoe gear immediately following the procedure. The success rate with RFNA appears to be quite high with fewer associated risks and less postoperative morbidity.
Hi Asher:
The difference between Plantar Fascia pain and Tarsal Tunnel/porta pedis pain can usually be appreciated via patient history, even before you actually examine him. Also, it is not unusual to find patients with both chronic plantar fasciitis as well as TT syndrome.
When suspecting TT syndrome (or porta pedis compression, which frequently are one in the same) it is helpful to inject 1cc of plain decadron into the TT. If the patient gets relief (even short term ) or temporary increased symptoms (sometimes severe) then your Dx is fairly certain.
Steve
__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA
Electrodiagnostic findings and surgical outcome in isolated first branch lateral plantar neuropathy: a case series with literature review.
Ngo KT, Del Toro DR. Arch Phys Med Rehabil. 2010 Dec;91(12):1948-51.
Quote:
Two patients with recalcitrant unilateral heel pain and plantar fasciitis were referred for electrodiagnostic evaluation. They both reported constant, sharp, unilateral medial heel pain, with nocturnal symptoms, as well as exacerbation by weight-bearing activities. Examination of both patients demonstrated focal medial heel tenderness and a Tinel sign over the tarsal tunnel on the affected side. Neither patient had weakness or sensory deficits in the affected foot. In both patients, findings on nerve conduction studies were normal in the affected foot, including the first branch of the lateral plantar nerve (FBLPN), as well as the medial and lateral plantar motor and sensory (ie, mixed nerve) responses. Needle electromyographic (EMG) abnormalities were found only in the abductor digiti quinti pedis (ADQP), an intrinsic foot muscle that is exclusively innervated by the FBLPN, but there were no EMG abnormalities noted in the medial or lateral plantar-innervated muscles studied, nor the contralateral ADQP. Both patients then underwent surgical decompression of the FBLPN. Postoperative follow-up (patient 1 at 10 months, patient 2 at 21 months) revealed excellent outcomes, as defined by symptom resolution, in both patients. Electrodiagnostic evaluation was useful in diagnosing isolated first branch lateral plantar neuropathy.
Neurogenic etiology of heel pain
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