Re: [at-l] Worm feet

[Snodrog5@aol.com]

Hi "Tender foot" :O)
I bookmarked these two sites from that thread
this first info is from a Doctor,
at the end is the url to "A Patient's Guide to Plantar Fasciitis"
TJ
http://www.allina.com/Allina_Journal/Spring1997/lutter.html
Plantar fasciitis
A guide to appropriate diagnosis and treatment 
Lowell D. Lutter, MD 
Contrary to conventional wisdom, plantar fasciitis is not an inflammatory 
disorder. Rather, it is a degenerative process and should be treated as such. 
In this article, Dr Lutter discusses the causes and differential diagnosis of 
plantar fasciitis, summarizes the diagnostic workup, and outlines his 
three-phase approach to treatment. Further, he warns of the erroneous premise 
of surgical procedures that involve the removal of too large a portion of the 
plantar fascia. 
Plantar fasciitis is one of the most common causes of heel pain, which 
accounts for approximately 15% of all foot-related complaints. The condition 
occurs in a wide variety of individuals. Most often, age at onset is in the 
mid-40s, but plantar fasciitis can develop at any age. Many studies have 
shown a female-male predominance of 3:1. Sixty-five percent of patients are 
overweight. Unilateral involvement is common, occurring in 70% of patients. 
About 22% of all patients with plantar fasciitis have moderate pronation; 
about 15% have a high-arched, rigid foot; and the remainder have an 
anatomically normal or nonaffected foot.1 Only 45% of patients who undergo 
radiography for suspected plantar fasciitis are found to have a subcalcaneal 
spur.2 
Causes
In almost every case, the primary anatomic cause of plantar fasciitis is some 
degree of microtrauma and tearing at the site of plantar fascia insertion. 
These abnormalities, which may also be present at the origin of the plantar 
fascia, result from repetitive trauma and lead to collagen degeneration and 
angiofibroblastic hyperplasia. 
Being overweight or obese places significant stress on the area and thus may 
be an important causative factor. Inflammation of the subcalcaneal bursa may 
also cause plantar fasciitis, as may compression of the median calcaneal 
nerve or the nerve to the abductor digiti quinti. In addition, systemic 
inflammatory disorders, such as rheumatoid arthritis, Reiter's syndrome, and 
psoriasis, may produce plantar fasciitis. 
Differential diagnosis
Before plantar fasciitis can be definitively diagnosed, several other 
conditions must be excluded. 

CALCANEAL STRESS FRACTURE--A calcaneal stress fracture may cause pain similar 
to that produced by plantar fasciitis. 

SUBCALCANEAL DISEASE--In subcalcaneal disease, the area surrounding the site 
of plantar fascia insertion is not painful. Unlike the pain of plantar 
fasciitis, which is located in the middle of the heel, subcalcaneal pain is 
present on the plantar surface of the heel. Subcalcaneal pain is most likely 
related to bursa formation and inflammation. 

HAGLUND SYNDROME--Trauma to the superior angle of the calcaneus produces 
inflammatory enthesopathy of the Achilles tendon. Patients who have Haglund 
syndrome usually experience pain during stair climbing and other activities 
that involve heavy use of the Achilles tendon. Rarely do they have pain on 
arising in the morning, which is characteristic of plantar fasciitis. 

ACHILLES' TENDINITIS--In this condition, pain and swelling are generally 
localized to the Achilles tendon. The swelling and crepitus caused by 
peritendinous edema can be significant. Patients with Achilles' tendinitis 
have pain during activity. 

TARSAL TUNNEL SYNDROME--Compression of the median plantar or lateral plantar 
nerve at the median of the calcaneus causes tarsal tunnel syndrome. Often, 
Tinel's sign is elicited by percussion of the nerve. In many cases, 
electromyographic findings are inconclusive. 

CALCANEAL APOPHYSITIS--This condition is limited to growing, active children 
with open apophyses. Pain is localized below the insertion of the Achilles 
tendon. Deep palpation of the affected area produces significant discomfort. 
Calcaneal apophysitis resolves on fusion of the apophyses, which occurs as 
these patients mature. 

Diagnosis
At history taking, most patients with plantar fasciitis state that they have 
pain the instant their affected heel touches the floor in the morning. The 
pain lessens with time and activity. However, if they sit for some time 
during the day, they experience "restart" pain when they stand. Most patients 
experience activity-related discomfort intermittently throughout the day. 

Physical examination often reveals that the range of motion of the ankle on 
the affected side is less--usually by no more than 5 degrees--than that of 
the contralateral ankle. By pressing a thumb against the middle of the 
affected heel, the physician can delineate the area of plantar fascial pain. 
Pressure similarly applied underneath the calcaneus reveals the area of 
subcalcaneal pain. 

Radiographic findings are not specific. As already stated, the correlation 
between plantar fasciitis and subcalcaneal spurs is not significant. 
Anteroposterior and lateral views are used to rule out calcaneal stress 
fracture or other bone abnormalities. Fat pad atrophy can be demonstrated 
radiographically in some older patients. 

Electromyography is rarely helpful diagnostically. In some cases of plantar 
fasciitis, ultrasonography shows a thickened fascia at the tip of the heel. 
Often, a technetium Tc 99m bone scan reveals increased isotope uptake at the 
site of plantar fascia insertion. 

Treatment
Conservative treatment resolves plantar fasciitis in 85% of patients. In the 
15% of patients in whom this approach fails, surgery is indicated. 

CONSERVATIVE TREATMENT--I use a sequentially phased regimen to treat patients 
with plantar fasciitis. 

PHASE 1--During this phase, an exercise program that involves stretching of 
the plantar fascia and Achilles tendon and strengthening of the anterior 
tibial muscle is instituted. In addition, a fiberglass splint fabricated to 
extend the foot to its full length and place the heel at a 90-degree angle is 
worn during sleep. A semiflexible orthotic device with additional 
longitudinal arch support is constructed for use during the day. The patient 
wears these devices and continues the exercise program for 6 to 8 weeks; if 
absolutely no improvement is noted at the end of this period, a follow-up 
visit is scheduled. 

PHASE 2--At the follow-up visit, blockade of the medial calcaneal nerve or 
the nerve to the abductor digiti quinti with lidocaine is carried out to 
determine whether nerve compression exists. Corticosteroid administration is 
helpful only in decreasing the inflammatory response. Although one or two 
injections of a corticosteroid may provide prolonged symptomatic relief, 
permanent relief is possible only if such therapy is combined with phase 1 
measures. Use of nonsteroidal anti-inflammatory drugs results in short-term 
pain relief. 

PHASE 3--After the follow-up visit, a short walking cast or a fiberglass 
ankle brace is worn for 3 weeks. If the patient is then pain-free, 
maintenance physiotherapy is beneficial. 

SURGERY--For patients who are not pain-free after completion of 9 to 11 
months of nonsurgical treatment, direct or endoscopically guided surgical 
release of the plantar fascia or the nerve to the abductor digiti quinti is 
warranted. Surgical techniques that involve partial or complete resection of 
the plantar fascia are based on the erroneous premise that total release of 
the plantar fascia is necessary. Currently, removal of only a small (one 
third) portion of the plantar fascia is recommended. 

Comment
Plantar fasciitis is not an inflammatory but rather a degenerative process. 
Nonetheless, a great number of inappropriate therapeutic procedures and 
orthotic devices have been used in response to the erroneous belief that 
inflammation is the problem. Usually, the use of corticosteroids, 
nonsteroidal anti-inflammatory drugs, and heel cups is ineffective in the 
long run. Clearly, treatment of plantar fasciitis must focus on resolving the 
fasciosis or tendinosis present and thus should consist of rest, stretching 
exercises, muscle strengthening, and pressure relief.1,3 

 the url to "A Patient's Guide to Plantar Fasciitis"
http://www.sechrest.com/mmg/foot/heelspur/heelspur.html
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