Central Florida Foot & Ankle Center, LLC
101 6th Street N.W.
Winter Haven, FL 33881
Heel pain is a common problem that many podiatrists see daily in their busy practices. As foot and ankle physicians, we treat this malady quite frequently with a variety of treatment methods. Before we concern ourselves with the actual treatment plans, let us understand a little background information about this condition.
Peripheral arterial disease, commonly referred to as P.A.D., is a clogging of the arteries with fatty deposits. These fatty deposits, or plaques, can build up over time, slowly narrowing the arteries in the body. When the arteries become hardened and narrowed, it may also be referred to as atherosclerosis. P.A.D. is most common in the lower extremities, but can also occur in the upper extremities and in vessels supplying major organs like the kidneys or stomach. When the vessels of the legs are affected, it can lead to significant changes, which some people may attribute to “poor circulation”.
Peripheral arterial disease can often indicate a problem in not just the vessels of the legs, but in all the vessels in the entire body. For this reason, people with P.A.D. are at an increased risk for heart disease and stroke. When atherosclerosis occurs in the vessels supplying blood to the heart, it is called coronary artery disease (C.A.D.)
About 8 million Americans are affected by P.A.D., and the numbers are on the rise. This is partly due to a greater effort to screen for peripheral arterial disease, but may also be attributed to a greater incidence of the disease and an increase in risk factors across the American population. Risk factors for P.A.D. include diabetes, smoking, high blood pressure, high cholesterol, and a history of heart disease or stroke. African Americans are also at an increased risk for developing P.A.D.
Peripheral arterial disease is a slowly-developing process in the body, and as such, the signs and symptoms of the disease can be slow to develop too. In fact, they can often go unrecognized. Most commonly, the symptoms will include pain and cramping in the legs, thighs, buttocks, or feet that occurs while walking and is relieved with rest. This is referred to as claudication, and is a reproducible pain. This means that the pain will appear with a consistent amount of activity, such as walking two blocks before the pain begins. This pain is attributed to a lack of oxygen to the muscles, most commonly in the leg, due to the narrowing of the arteries supplying the muscles. Other symptoms may include pain at night in the toes or feet that disturbs sleep, or slow healing wounds in the legs and feet.
In the podiatrist’s office, screening for P.A.D. becomes routine, particularly when patients are at an elevated risk for developing the disease. Screening involves checking for pulses in the feet, and monitoring the time it takes for the skin to return to a normal color after the blood is pressed from it (capillary fill time). The pulses in the feet can also be listened to with a hand-held Doppler device. This allows your podiatrist to listen to the blood flow into your feet, and have an idea of the condition of your vessels.
Common tests for diagnosing peripheral vascular disease include the use of segmental pressure measurements, ankle-brachial indices, measurement of toe pressures, and measurement of transcutaneous oxygen pressures. These tests can give a comprehensive analysis of the blood flow to the feet. If it is necessary, an arteriogram can also be performed. This test involves injecting a dye into the arteries, then taking x-rays to visualize the vessels. This is generally only done for surgical planning, when it is determined that there is a total or nearly complete occlusion of a vessel, and it must be visualized pre-operatively.
Treatment for P.A.D may involve surgery by a vascular surgeon to stent the vessels, or to create a bypass in the arteries. There are also medical treatments that can be used to bust up the clots in the arteries. The P.A.D. Coalition, a non-profit organization that promotes screening and education about peripheral vascular disease, recommends the following lifestyle changes that can help prevent or treat mild to moderate peripheral vascular disease:
Peripheral arterial disease has become a serious problem, and can lead to poor wound healing, gangrene, infection, and amputation. For this reason, it is commonly screened for in the podiatrist’s office. If you have any questions, or feel that you or someone you know may be affected by P.A.D., talk to your doctor today. Catching it early can make a huge difference in the outcome of the disease.
Lyme disease is a complex, multisystem illness that is caused by the microorganism Borrelia burgdorferi. Borrelia burgdorferi is a tick-borne spirochete, which is transmitted by Ixode ticks. The ticks act as a reservoir for the bacteria, which can then be transmitted through their bites. Typically the tick must stay attached to a human source for 24-48 hours in order to transmit the bacteria. The disease was first recognized in 1975 in Lyme, Connecticut, for which it is named.
Lyme disease can be broken down into three stages. The first stage begins after a period of 3-30 days, and is characterized by a classic “bulls-eye” lesion, also known as erythema migrans. This is pictured above, and is seen at the site of infection. It may be accompanied by fever, malaise, headache, and joint and/or muscle pain.
The second stage occurs 1-6 months following the initial stage. Arthritis is the main presenting symptom, with associated muscle pain and swollen lymph nodes. A certain percentage of patients will neurological symptoms, including meningitis or Bell’s Palsy. Some will present with carditis as well.
The third stage may occur months to years after exposure. There is chronic neurological involvement, most commonly a subtle form of encephalopathy that affects mood, memory, and sleep. Arthritis and muscle pain may be a chronic symptom by this stage.
Treatment of Lyme disease depends on the stage of the disease at presentation as well as the symptoms. Antibiotics are used in the early stages to fight the spirochete infection. Doxycycline, tetracycline, and amoxicillin have all been used. Neurological abnormalities may be treated with cephalosporins or penicillin. As for the arthritis associated with Lyme disease, the symptoms are generally treated much like any other arthritis. NSAIDs with or without intra-articular steroid injections may be of benefit.
Of course, the disease should be treated before it progresses from the first stage. With the presence of arthritis plus a history of possible exposure to ticks and a bulls-eye rash, antibiotics should be started. Laboratory testing is typically limited to a blood draw to look for IgM antibodies. However, this will often take 3-6 weeks to show up. Therefore, antibiotics may need to be started before an absolute diagnosis can be made. An ELISA test or a Western blot can be performed to confirm the diagnosis after empiric therapy is started.
Incidence of Lyme disease is most common in wooded areas. In particular, the disease persists in the Northeastern United States, as well as parts of Minnesota, Wisconsin, and Northern Michigan.
The term ‘pilon’ was first used in 1911 by French radiologist Destot to describe the ankle joint. It is derived from the French word for ‘pestle’, and helps to describe both the shape of the ankle joint as well as the mechanism of this type of injury. Pilon fractures occur when axial compression is applied through the ankle joint, exceeding the amount of force that the ankle can transmit through the body. When this happens, a serious injury may occur, shattering the tibia and sometimes the fibula as well.
Pilon fractures are uncommon, accounting for 7% of all tibia fractures and less than 1% of all lower extremity fractures. They are an interesting subject, however, due to the orthopedic challenges that they present. Many pilon fractures will also be open fractures, meaning that the skin has been compromised in the injury and the bone may actually be visibly protruding from the skin. Higher impact injuries, such as from a motor vehicle accident or a fall from a height will involve a fracture of both the tibia and fibula. Lower impact injuries, such as skiing accidents, may only involve a fracture of the tibia. These fractures are generally intra-articular, which adds to their complexity.
Classification systems for pilon fractures include the Ruedi and Allgower classification, which was the first one described in 1969. Later, the AO/OTA classification was established in 1996, which gave further detail as to the extent of the injury. Both systems differentiate between number of fracture fragments, displacement of fracture fragments, and articular involvement. These systems are useful in communicating the extent of the injury, however little intra- and inter-observer agreement has been seen with the use of either of the two systems.
Diagnosis of pilon fractures is made with medical imaging. X-rays are typically ordered first, followed by a CT scan. CT scans will allow the foot and ankle surgeon to visualize the number of fracture fragments and the arrangement of the injury, and will help in planning the surgical correction.
Because of the type of injury that causes a pilon fracture, the patient is usually brought in to the emergency room and is treated first by the trauma team. This would include management of airway, breathing, circulation, disability, and exposure to any contaminants and/or toxins. Once the patient is stabilized, the fractures may be treated. There is a high correlation between pilon fractures and spinal fractures, so imaging should include the entire vertebral column.
While historically pilon fractures have been treated conservatively, most physicians would agree that treatment with surgery is necessary to regain function of the limb. Early reasons to avoid surgery were poor outcomes and increased risks involved with surgery, however, modern surgery has evolved to have a much greater success rate than in the past.
Surgical treatment of pilon fractures is most commonly done in a two-stage fashion. The first stage involves putting an external fixation device on the leg. These are done as either ankle-spanning (pins are placed through the talus, the bone that sits in the ankle joint) or as ankle sparring (no pins are placed through the talus). Today, ankle-sparring procedures have become more popular as they decrease damage to the joint itself. The external fixator is used to help realign the fracture fragments, and uses the theory of ligamentotaxis to do so. Once the fragments have bee realigned, and most of the initial swelling has decreased since the injury, a more definitive procedure may be performed to fix the ankle and leg
This commonly involves the use of either metal plates or an intramedullary nail, or both. Intrameduallry nails are long nails that are placed longitudinally through the bone. This gives the bone strength and helps to realign the fractures. The plates will also help to realign fragments, particularly of the fibula, should it be involved in the fracture. A variety of techniques may be used surgically, depending on the extent of the injury and the damage done to the bones.
Prognosis of pilon fractures depends heavily on the extent of injury. Numerous studies have shown that the more significant the injury, the greater chances of post-operative complications, infection, delayed union, malunion, and non-union. Good results may be seen with fractures that show minimal displacement and comminution (meaning that there are several fracture fragments), though unsatisfactory results are more commonly seen with more extensive comminution, joint involvement, and displacement of fracture fragments. Advances to surgical technique have made the outcomes more favorable in recent years, yet there is still an increased risk of post-operative sequelae with more extensive injury.
A recent study published in the Journal of the American Podiatric Medical Association looked at limb-length discrepancy as a cause of plantar fasciitis. The article, written by Mahmood et al., analyzed 26 patients with unilateral heel pain that was previously diagnosed as plantar fasciitis. The limb-length of the patients was then measured, using a combination of methods. The results of the study showed that there was a strong correlation between a longer limb and unilateral plantar fasciitis pain.
Taking a further look at the results of the study, it was found that the vast majority of the unilateral heel pain was found on the same side of the body as the longer limb. Presumably, a longer limb would function in a more pronated position during stance. This would put extra strain on the plantar fascia, the large, thick strip of aponeurosis running along the bottom of the foot.
The study also looked at Body Mass Index (BMI) as a possible cause of plantar fasciitis, however, the results were not significant for these two factors to be correlated.
Plantar fasciitis is one of the most common conditions that podiatrsts see, and is the most common cause of heel pain in the adult population. There are a number of different theories on why it develops, most of which focus of the biomechanics of the foot and lower extremity. This study by Mahmood et al. is one of few peer-reviewed journal articles to research the etiology of the common disorder.
Treatments for planar fasciitis are as numerous as the possible causes of the problem. Conservative therapy includes things like stretching, ice, rest, temporary arch supports/padding, night splints, functional orthotic devices, and oral anti-inflammatory medications such as NSAIDs. Other measures may include corticosteroid injections, extracorporeal shockwave therapy (ESWT), or platelet-rich plasma (PRP) therapy. Still more drastic measures may include surgical intervention, when all other conservative therapies have failed.
The authors of the study highlight an important decision in the possible treatment of plantar fasciitis associated with a limb-length discrepancy. That is the use of a hell lift in addition to the use of a functional orthotic device. The hell lift addresses the difference in limb length, which may be the etiology of the condition. Thus, the treatment would address the root of the problem, and not merely the symptoms.
More research into the etiology of plantar fasciitis is warranted, as this is an extremely common condition. Limb-length may be just one of many possible causes, and more studies like this one will be needed to determine them.