Robert W. Mendicino

The diagnosis and treatment of heel pain: a clinical practice guideline-revision 2010.

Heel pain, whether plantar or posterior, is predominantly a mechanical pathology although an array of diverse pathologies including neurologic, arthritic, traumatic, neoplastic, infectious, or vascular etiologies must be considered. This clinical practice guideline (CPG) is a revision of the original 2001 document developed by the American College of Foot and Ankle Surgeons (ACFAS) heel pain committee.

The diagnosis and treatment of heel pain

Mechanical heel pain is one of the most frequent conditions presented to foot and ankle specialists. Plantar heel pain is responsible for the majority of mechanical heel pain cases. Plantar heel pain is defined as insertional heel pain of the plantar fascia with or without a heel spur (Fig. 1). The most common cause cited for plantar heel pain is biomechanical abnormalities that lead to pathologic stress to the plantar soft tissues (1–7). Localized nerve entrapment of the medial calcaneal or muscular branch off the lateral plantar nerve may be a contributing factor (8–11). Patients usually present with isolated plantar heel pain upon initiation of weightbearing, either in the morning upon arising or after sitting for a period of rest. The pain tends to decrease after a few minutes, then returns as the day proceeds and time on the feet increases. Associated significant findings may include high body mass index, tightness of the Achilles tendon, pain upon palpation of the inferior heel, and inappropriate shoe wear (12–14). Many patients will have attempted self-remedies before seeking medical advice. A careful history is important, including time(s) of day when pain occurs, current shoe wear, activity level both at work and at leisure, and history of trauma. An appropriate physical examination of the lower extremity includes range of motion of the ankle with special attention to decreased range of motion of dorsiflexion of the ankle, palpation of the inferior medial aspect of the heel, palpation of the medial aspect of the heel, the occurrence of bilateral symptoms, and angle and base of gait evaluation. Following physical evaluation, appropriate radiographs may be considered. Radiographic identification of a plantar heel spur indicates that the condition has been present for at least 6–12 months, whether having been symptomatic or not (Fig. 2). As a rule, the longer the duration of heel pain symptoms, the longer the period to final resolution of the condition. Initial treatment options may include nonsteroidal antiinflammatory drugs (NSAIDs), padding and strapping of the foot, and corticosteroid injections for appropriate patients. Patient-directed treatments seem to be as important in resolving symptoms. They include regular stretching of the calf muscles, avoidance of flat shoes and barefoot walking, use of cryotherapy directly to the affected part, over-the-counter arch supports and heel cushions, and limitation of extended physical activities. Patients usually have a clinical response within 6 weeks of initiation of treatment. If improvement is noted, the initial therapy program is continued until symptoms are resolved. If no improvement is noted, the patient should be referred to a podiatric foot and ankle surgeon. The second phase of treatment for the referred patient includes continuation of the initial treatment options with considerations for additional therapy: the use of custom orthotic devices, especially in the biomechanically malaligned patient, the use of night splints to

Oblique medial malleolar osteotomy for the management of talar dome lesions

The purpose of this retrospective study was to determine the efficacy of the oblique medial malleolar osteotomy for the management of medial talar dome lesions. Arthroscopy remains a viable option for the management of these lesions; however, the central and posteromedial lesions are often difficult to gain access to with arthroscopy and may require open arthrotomy. Fourteen oblique medial malleolar osteotomies were performed for the surgical management of medial talar dome lesions. Subjective data were collected through the process of questionnaire. Objective criteria consisted of radiographic evaluation and retrospective medical record review. Seven of the 14 patients related a history of trauma preoperatively. The oblique medial malleolar osteotomy demonstrated osseous union at an average of 6.6 weeks. There were no delayed unions or nonunions. None of the patients required a second operative procedure. Nine patients reported excellent postoperative results, two patients had good results, two had fair results, and one patient related a poor postoperative outcome with only 50% relief of pain. Patients greater than the age of 30 were found to have less favorable results. Follow-up ranged from 6 to 72 months, with a mean follow-up of 34 months.

Lateral ankle instability and the brostrom-gould procedure

Lateral ankle instability can present as either acute or chronic. Proper identification of the etiology is necessary to determine the proper treatment plan. The Brostrom-Gould procedure, when properly used, can provide adequate correction of the unstable ankle. A review of the procedure, its indications, and the results of 44 patients who underwent the procedure will be discussed.

Techniques for harvesting autogenous bone grafts of the lower extremity

Autogenous bone grafts have several advantages over allogenic bone grafts, especially when being used for arthrodesis or for revision of malunions or nonunions. Procurement of these grafts can come from remote regions or from areas adjacent to the operative site. The lower extremity provides a source for obtaining cortical, corticocancellous, and cancellous bone for use in foot and ankle surgery. Harvesting techniques do not come without complications and the necessity for proper techniques in handling is crucial.

ACFAS universal foot and ankle scoring system: First metatarsophalangeal joint and first ray (module 1)

The American College of Foot and Ankle Surgeons presents the Universal Evaluation Scoring System to evaluate parameters related to foot and ankle surgery. This instrument was developed primarily to allow investigators a means of consistency in clinical assessments. The project was developed in four sections or modules. The first of these modules, First Metatarsophalangeal Joint and First Ray, is presented. This project is unique in that it is the first clinical scoring system of the foot and ankle to become validated by statistical analysis.

Chondroblastoma of the calcaneus: Literature review and case presentation

Chondroblastoma is a benign neoplasm of bone and most often arises from the epiphysis of long bones. Recognition of this tumor can be difficult and is often only confirmed on histological examination. Radiographic studies can demonstrate findings that mimic other tumors such as giant cell and aneurysmal cysts. Proper identification and management of this tumor has as high as a 90% success rate in eradication.

ACFAS universal foot and ankle scoring system: Forefoot (Module 2)

The American College of Foot and Ankle Surgeons developed the Universal Evaluation Scoring System to evaluate parameters related to foot and ankle surgery. The project was developed in four sections or modules. The second of these modules, Forefoot, is presented here.

Bone grafting in the surgical management of osseous neoplasms

The diagnosis and treatment of osseous neoplasms are challenges for the foot and ankle surgeon. Osseous neoplasms are potentially debilitating, thus appropriate diagnosis and management are critical to success. Resection of these lesions can result in large osseous deficits, requiring bone grafting for replacement. The graft may provide osteogenesis, structural support, or both. This article presents possible surgical therapeutic alternatives in management of benign and low-grade malignant osseous neoplasms in the foot and ankle.