Nerve entrapment in painful heel syndrome

Subcalcaneal heel pain is one of the most common foot ailments, yet the exact etiology is still controversial. Nerve entrapment has been suggested as one of the possible causes of this painful condition in recalcitrant cases. The purpose of this study is to determine the role of nerve entrapment in painful heels. Twenty patients with heel pain (25 heels) were compared with an age and body mass index-matched control population using electrodiagnostic methods. The results of the study revealed 22 heels (88%) with heel pain had lateral plantar nerve entrapment signs with or without medial plantar nerve findings on EMG. There were no abnormal values in the control group. Nerve entrapment syndrome has previously been considered only in cases with intractable heel pain, but this study suggests that it may play a role the early phases of painful heel syndrome.     

The plantar approach to heel surgery: a retrospective study.

The authors' present a plantar surgical approach for the patient with painful heel syndrome that is refractory to conservative care. Patient selection, methods, and results are discussed and analyzed. Twenty-two patients with 25 painful heels underwent the procedure. Retrospective analysis of these patients clearly shows this procedure is a viable alternative for heel surgery.     

Extracorporal shock wave therapy in patients with tennis elbow and painful heel

The aim of this study was to evaluate the effect of extracorporal shock wave therapy (ESWT) in tennis elbow and painful heel. Nineteen patients with tennis elbow and 44 patients with painful heel in which conservative treatment had failed underwent ESWT. Both groups received 3000 shock waves of 0.12 mJ/mm2 three times at weekly intervals. After a follow-up of 5 and 6 months respectively, pain measured on a visual analogue scale (VAS) decreased significantly in both groups. The success rate (excellent and good results) was 63% in tennis elbows and 70% in painful heels. ESWT seems to be a useful conservative alternative in the treatment of both conditions.     

Diagnostic dilemma: crusted scabies superimposed on psoriatic erythroderma in a patient with acquired immunodeficiency syndrome

A 45-year-old man with AIDS presented with extensive erythema and scaling involving the face, trunk, and upper and lower extremities, and mild nail dystrophy. The patient had been diagnosed with psoriasis 2 years previously, and at the time of presentation was using emollients and topical corticosteroid creams with little improvement. He was receiving zidovudine, lamivudine, trimethoprim/sulfamethoxazole, acyclovir, rifabutin, and hydroxyzine. Pertinent laboratory data included CD4 lymphocytes (10 cells/mm(3)), viral load (32,000 copies per mL) white blood cell count (3.4 x 10(3)/microL), hemoglobin (13.5 g/dL), and platelets (204 x 10(3)/microL). Because of the extensive eruption and lack of response to topical agents, the patient was started on acitretin 25 mg daily. The patient had shown no signs of improvement 4 weeks later and was noted to have brownish gray crusted plaques involving the beard area, neck, upper part of the back, arms, trunk, genitals, and thighs in addition to his erythroderma (Figure 1 and Figure 2). Microscopic examination of scales from the upper part of the back revealed numerous scabies mites and eggs. He was then treated with lindane shampoo on the scalp and beard area and permethrin 5% cream to the body. The patient returned 2 weeks later with some improvement after thrice-weekly applications of this regimen; however, scrapings from the trunk once again revealed live scabies mites. Microscopic examination of scales that had fallen on the examination table revealed multiple mites and eggs. The patient was then given permethrin 5% cream, which he applied 3 times a week for 2 weeks, and 1 dose of oral ivermectin, 200 micro/kg. This resulted in a marked decrease in crusting and scaling. With resolution of the scabies lesions, the patient displayed marked erythema and scaling of the trunk and extremities consistent with generalized psoriasis (Figure 3). Treatment with acitretin resulted in gradual resolution of the erythroderma. A few months later, the patient presented with nodules on the upper part of the back, which on biopsy revealed a scabies mite (Figure 4).     

Tibialis posterior insufficiency occurring in a patient without peronei: a mechanical etiology.

A patient presented with a painful flatfoot deformity, which developed after the onset of a drop-foot secondary to a herniated lumbar disk. On examination, the only functioning muscles were her gastrocnemius-soleus complex and her intrinsic toe flexors. Her affected foot had taken the classic deformity seen with tibialis posterior dysfunction--a valgus heel, midfoot collapse and an abducted forefoot. Peroneus brevis was not functioning and therefore could not be implicated as part of the etiology of this patient's acquired flatfoot deformity. The mechanism in which the ground reaction force produces the foot deformity in a tibialis posterior insufficient foot will be presented.     

Sagittal Resection Osteotomy With Bone Block Distraction Subtalar Fusion for Treatment of Malunited Calcaneal Fractures

The aim of this prospective study was to evaluate the results of combined lateral sagittal resection osteotomy with subtalar distraction fusion in heels with painful malunion of the os calcis. This case series included 22 patients (23 feet). The mean age of the patients was 37.52 years. Sixteen (69.6%) patients were initially treated conservatively, 5 (21.7%) patients were treated surgically, and 2 (8.7%) patients were missed. The mean time lapsed before surgery was 11.43 months. A wedge of bone was resected to reduce the width of the malunited os calcis and was used as a local graft for subtalar joint fusion and to increase the height of the os calcis. The mean follow-up period was 56.83 ± 6.09 months. According to the scoring system, satisfactory results were found in 18 (82.6%) patients, and 4 (17.4%) patients had unsatisfactory results. Postoperative radiographic assessment revealed an average increase in the heel height of 7.70 ± 1.22 mm and an average decrease in heel width of 8.39 ± 1.47 mm. The average correction in the coronal axis was approximately 8.04° ± 1.26°. Complications included infection and nonunion in 3 (13%) heels. Two heels still had residual varus postoperatively, and 1 patient had injury to the sural nerve. The restoration of heel height, the reduction in heel width, and the primary fracture pattern had a significant relation with the final score. This method is a successful method for the management of subtalar arthritis caused by malunited calcaneal fractures with broadening leading to lateral abutment.     

Acute salicylate intoxication after trancutaneous absorption]

Topical salicylate preparations are primarily employed as keratolytic agents in the treatment of dermatologic disorders. A case of severe salicylate intoxication in a 70-year-old man with psoriasis, treated with a topical cream containing salicylic acid, is described. After five days the patient was admitted to ICU with encephalopathy and severe acid-base disturbances (respiratory alkalosis, metabolic acidosis, increased anion gap). A plasma salicylate concentration was elevated at 695 mg/Lt. Emergent hemodialysis was accompanied by a rapid lowering of plasma salicylate concentration and resolution of metabolic acidosis. Salicylate is well absorbed by normal and diseased skin. In this patient the lack of a normal epidermal barrier greatly enhances absorption of topical salicylate. It is therefore suggested that all topical salicylate treatments should be routinely monitored with salicylate blood concentration especially during the initial few days after onset or after any changes in treatment.     

Granular parakeratosis: response to calcipotriene and brief review of current therapeutic options

A 34-year-old Hispanic woman presented with an 18-month history of an intermittent, asymptomatic eruption that began on her left axilla after using a depilatory cream containing corn starch and thioglycolate (Figure 1A). The eruption then spread to her right axilla and lower abdomen (Figure 1B). She reported worsening with deodorant use, but had been using the same deodorant for many years and had continued using it twice a day. Treatment with topical corticosteroids had not helped. The patient coincidentally had been started on isotretinoin 5 months previously for acne, but it had no effect on her axillary or abdominal lesions. Physical examination revealed multiple dark brown and black papules with a "stuck-on" appearance in both axillae and on the lower right abdomen. A biopsy of the left axilla revealed a thickened parakeratotic stratum corneum with retention of keratohyalin granules within the parakeratoric cells, which is considered diagnostic of granular parakeratosis (Figure 2). The patient was prescribed calcipotriene cream twice daily. After 2 weeks, she had complete resolution of the axillary lesions, but the abdominal lesions persisted. She has since had mild recurrences while using calcipotriene.     

Prevention and management of calcaneal apophysitis in children: an overuse syndrome

Calcaneal apophysitis (Sever disease) is a common cause of heel pain, particularly in the athletically active child. Eighty-five children (137 heels) with calcaneal apophysitis were reviewed. Both heels were affected in 52 (61%) patients. The most common associated foot condition was pronation, occurring in 16 patients. Sixty-eight patients complained that pain was made worse by a specific sport, with soccer leading the list. All patients were treated with a physical therapy program of lower extremity stretching, especially of the heel cords, and ankle dorsiflexion strengthening. Soft Plastizote orthotics or heel cups were used in 98% of patients. Proper athletic shoewear was advised. All patients improved and were able to return to their sport of choice 2 months after the diagnosis. There were two recurrences.     

Bilateral chronic proximal plantar fasciopathy: treatment with electrohydraulic orthotripsy

BACKGROUND: Patients presenting for treatment of chronic plantar fasciopathy often have bilateral involvement. When various nonoperative treatments fail, subsequent intervention may be problematic, especially since bilateral surgery (bilateral fascial release) may not be realistic because of variable, frequently restrictive postoperative weightbearing limitations. METHODS: Twenty-three patients (46 heels) were treated with electrohydraulic high-energy orthotripsy to the plantar entheses of both feet while under the same anesthesia (conscious sedation). Following orthotripsy, all patients immediately were fully weightbearing and resumed normal activities of daily living and work, usually within 24 hours. Progressive return to athletic activities was allowed. Patients were assessed by three outcome parameters: (1) pain measured objectively by a dolorimeter combined with the patient's subjective evaluation of the level of pain; (2) pain after 5 minutes of walking upon arising; and (3) pain with daily activities. All pain measurements were done by the visual analog scale. RESULTS: Patients initially experienced varied pain relief responses. This included earlier pain relief in one heel compared to the other, as well as better pain relief in one heel than the other at the 6- and 12-week evaluations, but with much less variance at the 1-year evaluation. By 3 months following orthotripsy, 28 heels (61%) had good or excellent results. These results were maintained or improved at 1 year. In 18 heels (39%), the outcome was fair or poor. Nineteen heels received a second orthotripsy application; one patient requested a second orthotripsy treatment of only one heel, while nine patients requested a second treatment of both heels. The outcome showed further improvement following the second application of orthotripsy. At 1 year after one or two orthotripsy applications, 19 patients (38 heels) were satisfied with the results in both heels (83%), while four patients (eight heels) still had an unsatisfactory outcome (17%). CONCLUSION: Electrohydraulic high-energy orthotripsy is a reasonable nonincisional method for treating patients with bilateral chronic proximal plantar fasciopathy under a single anesthetic without the prolonged nonweightbearing status often recommended for patients following unilateral open or endoscopic fascial release.     

跟痛症的针刀分型论治

目的:将跟痛症进行分型,针对不同分型运用小针刀给予不同的治疗以提高疗效。方法:2005年8月至2008年12月治疗200例266跟,门诊189例251跟,住院11例15跟;男83例,女117例;年龄26～72岁,平均46岁;病史3～36个月,平均6.8个月。按笔者分型标准,分为跖筋膜炎型67跟,跟骨下滑囊炎型61跟,足底脂肪垫炎型36跟,跟骨内压增高型6跟,神经卡压型21跟,混合型75跟。采用小针刀针对不同的分型运用不同的疗法进行治疗。结果:完成治疗后1个月跖筋膜炎型治愈31跟,显效36跟;跟骨下滑囊炎型治愈32跟,显效29跟;足底脂肪垫炎型治愈9跟,显效20跟,好转4跟,无效3跟;跟骨内压增高型治愈1跟,显效3跟,好转2跟;神经卡压型治愈11跟,显效8跟,好转1跟,无效1跟;混合型治愈16跟,显效46跟,好转5跟,无效8跟。完成治疗后6个月以上的电话随访,跖筋膜炎型治愈21跟,显效40跟,好转5跟,无效1跟;跟骨下滑囊炎型治愈30跟,显效28跟,好转3跟,无效0跟;足底脂肪垫炎型治愈15跟,显效18跟,好转2跟,无效1跟;跟骨内压增高型治愈0跟,显效3跟,好转3跟,无效0跟;神经卡压型治愈7跟,显效11跟,好转1跟,无效2跟;混合型治愈10跟,显效45跟,好转11跟,无效9跟。结论:在临床工作中不能用单一的发病机制来解释跟痛症的病因,更不能用单一的方法来治疗,应将跟痛症进行分型,并针对不同的分型给予不同的治疗,这样才能提高跟痛症的治愈率。     

Long-term follow-up of patients with clubfeet treated with extensive soft-tissue release

BACKGROUND: Although long-term follow-up studies have shown favorable results, in terms of foot function, after treatment of idiopathic clubfoot with serial manipulations and casts, we know of no long-term follow-up studies of patients in whom clubfoot was treated with an extensive surgical soft-tissue release. METHODS: Forty-five patients (seventy-three feet) in whom idiopathic clubfoot was treated with either a posterior release and plantar fasciotomy (eight patients) or an extensive combined posterior, medial, and lateral release (thirty-seven patients) were followed for a mean of thirty years. Patients were evaluated with detailed examination of the lower extremities, a radiographic evaluation that included grading of osteoarthritis, and three independent quality-of-life questionnaires, including the Short Form-36 Medical Outcomes Study. RESULTS: At the time of follow-up, the majority of patients in both treatment groups had significant limitation of foot function, which was consistent across the three independent quality-of-life questionnaires. No significant difference between groups was noted with regard to the results of the quality-of-life measures, the range of motion of the ankle or the position of the heel, or the radiographic findings. Six patients who had been treated with only one surgical procedure had better ranges of motion of the ankle and subtalar joints (p < 0.004) than those who had had multiple surgical procedures. CONCLUSIONS: Many patients with clubfoot treated with an extensive soft-tissue release have poor long-term foot function. We found a correlation between the extent of the soft-tissue release and the degree of functional impairment. Repeated soft-tissue releases can result in a stiff, painful, and arthritic foot and significantly impaired quality of life.     

Treatment of chronic heel pain by surgical release of the first branch of the lateral plantar nerve.

Sixty-nine heels (53 patients) with chronic heel pain had a surgical release of the first branch of the lateral plantar nerve. The average duration of heel-pain symptoms was 23 months (range, six months to eight years). No patient had less than six months of conservative treatment before surgery. The average duration of preoperative conservative treatment was 14 months. Forty-four patients (83%) had taken nonsteroidal antiinflammatory agents. Sixty-three heels (91%) had used heel cups and/or orthoses. Fifty-nine heels (86%) had received one or more injections of a steroid preparation. Thirty-four heels had developed pain initially during a sports activity. Postoperatively, 61 heels (89%) had excellent or good results; 57 heels (83%) had complete resolution of pain. The average follow-up period was 49 months. In general, heel pain resolves with conservative treatment. In recalcitrant cases, however, entrapment of the first branch lateral plantar nerve should be suspected. Surgical release of this nerve can be expected to provide excellent relief of pain and facilitate return to normal activity.     

Static load response of the heels of SACH feet

Excessive heel hardness in the prosthetic foot is a frequent problem that may contribute to decreased function in the above knee and below knee amputee. Optimal mechanical characteristics of the SACH (solid ankle cushion heel) foot have not been defined. In an effort to characterize the mechanical properties of the heels of these feet, we performed static load-deformation tests on the heels of SACH feet at stimulated heelstrike. These data were interpreted using least squares fitting of the natural logarithms of the load-deformation data. Statistical comparison of these data revealed no significant difference in the static response of the "medium" and "regular" grades of foot. A difference at the 1% level of confidence was found between the "soft" grade and the two firmer grades. Consistency within a grade of foot was quite good. Comparison of feet from another manufacturer revealed no difference in static response, suggesting consistency in static performance among manufactures. It was our clinical impression that all grades of SACH heels are too stiff.     

A comparison of the tolerability of adapalene 0.1% cream and adapalene 0.1% lotion in healthy individuals

Two separate single-center, randomized, evaluator-blinded, bilateral (split-face) comparison studies compared the tolerability of adapalene 0.1% cream with adapalene 0.1% lotion in individuals with healthy skin treated once per day for 3 weeks. At each visit, the participants were graded on erythema, scaling, dryness, and stinging/burning (scale: 0 = none to 3 = severe). On the final study visit, the participants completed a Cosmetic Acceptability Questionnaire. Adverse events were recorded at each study visit. A total of 144 participants were enrolled and 130 completed the studies (study 1, n = 66; study 2, n = 64). The lotion formulation was non-inferior to the cream for the success rates and tolerability assessments in both studies. The frequency distributions of worst scores of either 0 (none) or 1 (mild) (study 1; study 2) for adapalene lotion were erythema (98.5%; 40.7%), scaling (100%; 73.5%), dryness (100%; 68.8%), and stinging/burning (98.5%; 100%). The most common treatment-related adverse event was dryness (study 1, cream 2.7% [2 of 75] and lotion 4.0% [3/75]); study 2, cream 2.9% [2 of 69] and lotion 4.3% [3 of 69]. Both the adapalene 0.1% cream and 0.1% lotion formulations were well tolerated and acceptable to the study participants. The adapalene 0.1% lotion provides clinicians with a retinoid for the treatment of acne in a lotion formulation.     

Botulinum toxin-induced resolution of axillary granular parakeratosis

A 44-year-old woman presented with an 18-month history of a pruritic dermatitis in the axillae bilaterally, beginning in the springtime. There was no history of significant hyperhidrosis. The patient did not recall any change in deodorant, soap, detergent, or other topical products. Her family history was unremarkable for anyone with similar symptoms. Physical examination revealed hyperpigmented plaques on an erythematous base in both axillae. The inframammary and intertriginous folds were free of lesions. Histologic examination taken from the left axilla was notable for mild digitate papillomatosis, compact hyperparakeratosis with large nuclei, and retained keratohyaline granules within the stratum corneum (Figure), consistent with axillary granular parakeratosis. A periodic acid-Schiff stain was negative for hyphae. Patch testing utilizing the thin-layer rapid-use epicutaneous test (T.R.U.E. Test, Mekos Laboratories, Hillerod, Denmark) was unremarkable. The patient was initially treated with fluticasone propionate 0.05% cream without notable improvement. She then received Clostridium botulinum type A neurotoxin injections to the axillae (50 U/axilla) with complete resolution of the rash within a few days. At 6-months' follow-up, the patient remained asymptomatic.     

Psoriatic erythroderma associated with enalapril

A 59-year-old man with a 35-year personal and positive family history of psoriasis was admitted to our department for treatment of psoriatic erythroderma. The patient had commenced therapy with enalapril 10 mg b.i.d. for the treatment of hypertension approximately 6 weeks before hospitalization. Five weeks after the initiation of enalapril, his psoriasis began to flare, and for a period of about 1 week it reached the extent of erythroderma. The patient did not associate the psoriatic flare with other factors such as infections, trauma, or stress. The patient presented with diffuse erythema and pronounced desquamation covering his entire trunk, scalp, and extremities (Figure). Nearly 100% of the body surface area was involved. The palms and soles were also affected, displaying erythema, hyperkeratosis, and painful fissures. The nails showed pits, oil spots, and subungual hyperkeratosis. The patient also had psoriatic arthritis affecting the interphalangeal joints of his fingers. Laboratory tests revealed an elevated erythrocyte sedimentation rate, an elevated creatinine level of 180 mmol/L, a blood urea nitrogen level of 10.8 mmol/L, and a uric acid level of 716 mmol/L. Urinalysis showed proteinuria of 1.5 g/24 h. The patient's renal condition was diagnosed as chronic tubulointerstitial nephritis, most probably related to his dermatologic disease. Allopurinol and dietary measures were recommended. Following treatment with methotrexate and replacement of enalapril therapy, the erythema and scaling gradually subsided and became confined to his pre-eruptive chronic plaques (approximately 5% of body surface area). Rechallenge with enalapril was not performed.     

Extracorporeal shockwave therapy (ESWT) in patients with chronic proximal plantar fasciitis

The aim of this study was to compare the effect of extracorporeal shockwave therapy (ESWT) in patients with chronically painful proximal plantar fasciitis with a conventional conservative treatment consisting of nonsteroidal anti-inflammatory drugs, heel cup, orthoses and/or shoe modifications, local steroid injections and electrotherapy. Forty-seven patients (49 feet) with a previously unsuccessful conservative treatment of at least six months were randomized to two groups. Treatment of Group 1 (25 heels) started immediately with three sessions of ESWT (3000 shockwaves/session of 0.2 mJ/mm2) at weekly intervals. In the patients of Group 2 (24 heels) treatment was continued for 12 weeks. After this period they were treated using the protocol of Group 1. No significant difference of pain and walking time after further non-ESWT treatment (three months) was seen. Six months after ESWT pain decreased by 64% to 88% on the visual analog scale (VAS) and the comfortable walking time had increased significantly in both groups.     

Plantar fasciitis: how successful is surgical intervention?

Forty-three patients (47 heels) underwent decompression of the nerve to abductor digiti minimi with partial plantar fascia release for intractable plantar fasciitis over a 4-year period. Forty-one patients (45 heels) were available for follow-up. All of the patients had failed to respond to nonoperative treatment. The mean duration of symptoms before surgery was 34.8 months (range, 12-132 months), and the mean follow-up was 31.4 months (range, 11-66 months). Seventy percent of the patients in the study were overweight or obese. Before surgery, 39 patients (43 heels) rated their heel pain as severe. At follow-up, 34 of 45 (75.6%) of the heels were pain-free or only mildly painful. The mean visual analogue pain score dropped from 8.5 of 10 preoperatively to 2.5 of 10 postoperatively. Only four patients failed to report an improvement in their activity restrictions, and only one patient had a walking distance of under 100 m after surgery; this patient had been affected by a reflex sympathetic dystrophy. Overall, however, only 20 of 41 patients were totally satisfied with the outcome (48.8%). We recommend that the small group of patients who fail to respond to nonoperative treatment be considered for surgical intervention. The results in terms of symptomatic relief are generally good but in terms of patient satisfaction can only be rated as moderate. The patients should be counseled about the likely outcome of surgery.     

Treatment of painful heel syndrome with shock waves

In a prospective clinical study, the effectiveness of shock waves on painful heel syndrome in 80 patients (20 men and 60 women) with an average age of 48 years was investigated. Six patients had bilateral treatments. Each treatment consisted of 1,000 impulses of shock waves at 14 kV. A 100-point scoring system (70 points for pain and 30 points for function) was used for evaluation. The intensity of pain was measured with a visual analog scale from 0 to 10. The overall results were no complaints in 20.6%, significantly better in 52.9%, slightly better in 17.6%, and unchanged in 8.8% of 64 patients (68 heels) with 12 weeks followup; no complaints in 59.3%, significantly better in 27.7 %, slightly better in 13% of 52 patients (54 heels) with 6 months followup. None of patients' symptoms became worse. Seventeen patients (18 heels) who did not respond favorably to the first treatment had significantly better results after a second treatment. There were no device-related problems, and no systemic or local complications. Shock wave treatment is a new modality of therapy that is safe and effective in the treatment of patients with painful hell syndrome.