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In my experience the use of mechanical therapies for the enthesitis from the seronegative spondyloarthropathies is about 100% failure.
The enthesitis in these people is due to an inflammatory process from their disease, not from mechanical overload of the tissue, so why would mechanical therapies work?
You can read a lot in some podiatric texts that you should use low dye strapping, orthotics etc for this (ie the same treatments that get used for the 'routine' plantar fasciitis), but I question the experience of the authors who make these claims.
There is no evidence for or against using them (but there is something 'in press', but I not seen it yet).
The only thing that seems to be effective is the use of the newer biologic agents that are used to treat the disease process.
Also keep in mind that just because they have a seronegative spondyoarthropathy, and present with pain in an entheses, that are are not immune to the 'routine' plantar fasciitis and the pain has nothing to do with the disease process.
__________________ Craig Payne
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Last edited by Craig Payne : 29th April 2010 at 05:54 AM.
Reason: typo
I was aware that biological treatment is the gold standard.
Maybe I was trying to find a way, as podiatrist, to help this patient,
but I wanted to base it on evidence.
I take that rest and anti inflamatories (he's on DMARDs) will have to do
at this stage. However, I will take into account differential diagnosis before
treatment plan is agreed.
I would take the point of view that even tho heel raises might fail, they won't do any harm and should improve ankle function in gait. They are cheap and easy to stop using so why not try anyway. I always mobilise equinus ankle joints to see how they are after and take it from there. Even if the main pathology is inflammatory disease then excessive strain in those tissues won't exactly help the situation. Maybe the two interventions of DMARDs and strain reduction will work better than just one.
Just my thoughts
Cheers Dave
__________________
Descartes seems to consider here that beliefs formed by pure reasoning are less doubtful than those formed through perception.
If a patient with psoriatic arthritis presents with enthesitis, would you give him a heel raise for the short term management?
Also he's got bilateral genu varum, Tibial varum, ankle equinus and forefoot supinatus
Is there any evidence for the use of heel raises?
Thanks
Enthesitis is not a specific diagnosis since it does not describe the anatomical location of the inflammation.
Quote:
en·the·si·tis (ĕnˌthĭ-sīˈtĭs)
noun
Traumatic disease occurring at the point of attachment of skeletal muscles to bone, where recurring stress causes inflammation and often fibrosis and calcification.
I definitely don't think heel raises would work for supraspinatus enthesitis.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Enthesitis is not a specific diagnosis since it does not describe the anatomical location of the inflammation.
I definitely don't think heel raises would work for supraspinatus enthesitis.
Harsh, but fair.
I'm guessing from the original post by airamasor and subsequent postings that the tissue being discussed was the plantar fascia at it's calcaneal attachment. However, your definition of enthesitis creates a problem with that: "traumatic disease occurring at the point of attachment of skeletal muscles to bone, where recurring stress causes inflammation and often fibrosis and calcification". Since the plantar fascia is not a skeletal muscle, there can be no enthesitis of the plantar fascia by this definition.
I'm guessing from the original post by airamasor and subsequent postings that the tissue being discussed was the plantar fascia at it's calcaneal attachment. However, your definition of enthesitis creates a problem with that: "traumatic disease occurring at the point of attachment of skeletal muscles to bone, where recurring stress causes inflammation and often fibrosis and calcification". Since the plantar fascia is not a skeletal muscle, there can be no enthesitis of the plantar fascia by this definition.
I've never hear plantar fasciitis called "enthesitis". The point is, with any of these clinical questions from members of Podiatry Arena where our clinical expertise is being requested, the rest of us shouldn't have to guess where the pain is located within the body of the patient. The person asking the question should make that very clear in the very first posting.
Quote:
Enthesitis
From Wikipedia, the free encyclopedia
Enthesitis is an inflammation of the entheses, the location where a bone has an insertion to a tendon or a ligament. It is also called enthesopathy, or any pathologic condition involving the entheses. The entheses are any point of attachment of skeletal muscles to bone, where recurring stress or inflammatory autoimmune disease can cause inflammation or occasionally fibrosis and calcification. One of the primary entheses involved in inflammatory autoimmune disease is at the heel.
It is associated with HLA B27 arthropathies like ankylosing spondylitis, psoriatic arthritis, and reactive arthritis. Symptoms include multiple point tenderness like at heel, tibial tuberosity, iliac crest, and others.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
I've never hear plantar fasciitis called "enthesitis". The point is, with any of these clinical questions from members of Podiatry Arena where our clinical expertise is being requested, the rest of us shouldn't have to guess where the pain is located within the body of the patient. The person asking the question should make that very clear in the very first posting.
When I went to school we were taught all about plantar "enthesopathy" whatever that is. The point you make is valid, the leg I pulled is equally valid... thanks for the alternative definition. Are you actually going to do some work in Italy, or just tour the sites?
When I went to school we were taught all about plantar "enthesopathy" whatever that is. The point you make is valid, the leg I pulled is equally valid... thanks for the alternative definition. Are you actually going to do some work in Italy, or just tour the sites?
Mostly vacation for now. Lectures in Rome start next Friday AM. Just went through my lecture schedule a few minutes ago. Have 4 hours and 50 minutes of lecture on Friday and 5 hours 45 minutes of lecture on Saturday, all with simultaneous Italian-English translation. Should be fun!
Here's the Spanish Steps from this AM....just about a 2 minute walk from our apartment. Awesome!
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
I've never hear plantar fasciitis called "enthesitis". The point is, with any of these clinical questions from members of Podiatry Arena where our clinical expertise is being requested, the rest of us shouldn't have to guess where the pain is located within the body of the patient. The person asking the question should make that very clear in the very first posting.
My apologies for not being specific enough. I am a third year student using the forum to learn and I sometimes get things wrong.
The enthesitis is at the inserction of the Achilles tendon.
My apologies for not being specific enough. I am a third year student using the forum to learn and I sometimes get things wrong.
The enthesitis is at the inserction of the Achilles tendon.
Rosa
Rosa:
No worries. I was once a third year podiatry student....but that was 28 years ago.
In most cases, pain and swelling at the insertion point of the Achilles tendon is caused by retrocalcaneal bursitis or retrocalcaneal spurring. Yes, heel lifts, or shoes with higher heel height differential, do help (due to decreased tensile force on the Achilles tendon during weightbearing activites) along with twice daily icing, gradual stretching of the gastrocnemius-soleus three times daily, non-steroidal antiinflammatory drugs (NSAIDS) and avoidance of barefoot walking. I have also found that suggesting patients wear open-heeled shoes, such as clogs, helps the pain greatly since it decreases any compression/shearing force between the shoe heel counter and the osseous and soft tissues of the posterior calcaneus.
Hope this helps.
By the way, welcome to Podiatry Arena.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Man, you should take more trips to Italy; it obviously chills you out big time seeing buildings that are more than a couple of hundred years old.
We took the train from Rome to Venice this morning. Had a great vaporotto ride to our apartment on the quiet side of Venice. Then had a nice Italian dinner watching the sunset...a glass of wine...very nice!
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Heel raise for enthesitis?
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