Neurosensory testing of the medial calcaneal and medial plantar nerves in patients with plantar heel pain

Predictive factors of effective tibial nerve release in tarsal tunnel syndrome

BACKGROUND

Factors that may affect surgical decompression results in tarsal tunnel syndrome are not known.

METHODS

A retrospective single-center study included patients who had undergone surgical tibial nerve release. The effectiveness of decompression was evaluated according to whether the patient would or would not be willing to undergo another surgical procedure in similar preoperative circumstances.

RESULTS

The patients stated for 43 feet (51%) that they would agree to a further procedure in similar circumstances. Six feet with space-occupying lesions on imaging had improved results, but neurolysis failed in 9 feet with bone-nerve contact. Neurolysis was significantly less effective when marked hindfoot valgus (p = 0.034), varus (p = 0.014), or fasciitis (p = 0.019) were present.

CONCLUSIONS

If imaging reveals a compressive space-occupying lesion, surgery has a good prognosis. In feet with static hindfoot disorders or plantar fasciitis, conservative treatment must be optimized. Bone-nerve contact should systematically be sought.

Topographical Pressure Pain Sensitivity Maps of the Feet Reveal Bilateral Pain Sensitivity in Patients With Unilateral Plantar Heel Pain

BACKGROUND

Plantar heel pain is one of the most common foot pain conditions treated by health care providers.

OBJECTIVES

To investigate differences in topographical pressure pain sensitivity maps of the feet between patients with unilateral plantar heel pain and healthy individuals, and to determine the relationship between topographical pressure maps, pain intensity, disability, and fascia thickness.

METHODS

Thirty-five patients with unilateral plantar heel pain and 35 matched healthy controls participated in this cross-sectional, case-control study. Pressure pain thresholds (PPTs) were assessed over 7 plantar locations on each foot. Topographical pressure pain sensitivity maps of the plantar region were generated using the averaged PPT of each assessed point. Pain and related disability were assessed with a numeric pain-rating scale (0-10) and the Foot and Ankle Ability Measure, respectively. Plantar fascia thickness was measured via ultrasound. All outcomes were obtained by an assessor blinded to the participants' condition.

RESULTS

Topographical pressure sensitivity maps revealed lower bilateral PPTs in patients with plantar heel pain compared to healthy controls, and a higher PPT on the calcaneus bone (P<.01). Women had lower PPTs than men in all areas (P<.001). Individuals with plantar heel pain also had thicker fascia, but only on the affected side, compared to healthy controls. Higher pressure pain sensitivity in the foot was associated with higher pain intensity at first step in the morning and thicker fascia at the calcaneus bone.

CONCLUSION

People with unilateral plantar heel pain had generalized bilateral pressure pain sensitivity in the plantar region of the foot. Greater pain intensity and fascia thickness were associated with higher pressure pain sensitivity in people with plantar heel pain.

LEVEL OF EVIDENCE

Case-control study, level 4. J Orthop Sports Phys Ther 2019;49(9):640-646. Epub 26 Mar 2019. doi:10.2519/jospt.2019.8813.

Ultrasound-guided decompression surgery of the distal tarsal tunnel: a novel technique for the distal tarsal tunnel syndrome-part III

BACKGROUND

The aim of this study was to provide a safe ultrasound-guided minimally invasive surgical approach for a distal tarsal tunnel release concerning nerve entrapments.

METHODS AND RESULTS

The study was carried out on ten fresh-frozen feet. All of them have been examined by high-resolution ultrasound at the distal tarsal tunnel. The surgical approach has been marked throughout the course of the medial intermuscular septum (MIS, the lateral fascia of the abductor hallucis muscle). After the previous steps, nerve decompression was carried out through a MIS release through a 2.5 mm (± 0.5 mm) surgical portal. As a result, an effective release of the MIS has been obtained in all fresh-frozen feet.

CONCLUSION

The results of our anatomic study indicate that this novel ultrasound-guided minimally invasive surgical approach for the release of the MIS might be an effective, safe and quick decompression technique treating selected patients with a distal tarsal tunnel syndrome.

Ultrasound-guided decompression surgery of the tarsal tunnel: a novel technique for the proximal tarsal tunnel syndrome-Part II

Background

The aim of this study is to provide a safe ultrasound-guided minimally invasive surgical approach for a proximal tarsal tunnel release concerning nerve entrapments.

Methods and results

The study was carried out on ten fresh-frozen feet. All of them were examined by high resolution ultrasound at the medial ankle region. The surgical approach was marked throughout the course of the flexor retinaculum (laciniate ligament). Once the previous steps were done, the flexor retinaculum release technique was carried out with a 2-mm entry only. As a result, an effective and safe release of the flexor retinaculum was obtained in all fresh-frozen feet.

Conclusion

The results of our anatomic study indicate that our novel ultrasound-guided minimally invasive surgical approach for the release of the flexor retinaculum might be an effective, safe and quick decompression technique treating selected patients with a proximal tarsal tunnel syndrome.

Widespread Pressure Pain Hypersensitivity in Musculoskeletal and Nerve Trunk Areas as a Sign of Altered Nociceptive Processing in Unilateral Plantar Heel Pain

Our aim was to investigate the differences in pressure sensitivity over musculoskeletal and nerve symptomatic and distant areas between individuals with plantar heel pain and healthy subjects and to determine the relationship between sensitivity to pressure pain, foot pain, and fascia thickness. Thirty-five patients with unilateral chronic plantar heel pain and 35 matched healthy controls participated. Pressure pain thresholds (PPTs) were assessed bilaterally over several nerve trunks (median, radial, ulnar, common peroneal, tibial, and sural nerve trunks) and musculoskeletal structures (calcaneus, medial gastrocnemius, tibialis anterior, and second metacarpal) by an assessor blinded to the subject's condition. Pain was assessed with a numerical pain rating scale (0-10), impact of foot pain was assessed with the Foot Function Index, and plantar fascia thickness was measured via ultrasound imaging. Analysis of covariance revealed lower widespread and bilateral PPTs over both nerve trunks and musculoskeletal structures in individuals with plantar heel pain (P < .001). Female patients showed lower PPT than male patients in almost all points (P < .001). PPT over the peripheral nerve trunks of the lower extremity were significantly associated with the intensity of pain at first step in the morning and with the foot function disability scale of the Foot Function Index (P < .05). This study found widespread pressure pain hypersensitivity over both nerve trunks and musculoskeletal structures in individuals with unilateral chronic plantar heel pain, suggesting the presence of a central altered central nociceptive pain processing. Pressure hypersensitivity over nerve trunks on the lower extremity was associated with higher pain intensity and related disability. PERSPECTIVES: This study found widespread pressure hypersensitivity over both nerve trunks and musculoskeletal structures in individuals with unilateral chronic plantar heel pain, as a manifestation of a centrally altered central nociceptive pain processing.

Ultrasound-Guided Radiofrequency Denervation of the Medial Calcaneal Nerve

OBJECTIVE

Plantar fasciosis is a common complaint of athletes, particularly for runners. The medial calcaneal nerve (MCN) may play a role in the pain syndrome, and radiofrequency (RF) denervation has been previously reported. The hypothesis is that ultrasound-guided denervation of the MCN results in symptomatic improvement.

DESIGN

Retrospective cohort.

SETTING

Private practice.

PATIENTS

Twenty-nine patients previously receiving ultrasound-guided RF denervation of the MCN, having failed conservative therapy, were assessed in 2 groups, those more than (group 1, n = 16) or less than (group 2, n = 13) 6 months since the procedure.

INTERVENTIONS

Ultrasound-guided RF denervation of the MCN.

MAIN OUTCOME MEASURES

Pain scores before denervation, as well as at maximal pain relief and the time of the interview. Levels of satisfaction and attitudes toward surgery were also assessed.

RESULTS

Pain scores decreased significantly in both groups, for both best and residual pain scores. Group 1 mean pain scores were 8.56 before procedure, 2.81 (P < 0.001 compared to baseline) at best pain score, and 3.75 (P < 0.01) residual pain score. Group 2 mean pain scores were 7.23 before procedure, 3.77 (P < 0.01) at best pain score and 4.92 (P < 0.01) residual pain score. Levels of satisfaction were predominantly positive (69% of group 1% and 54% of group 2 were either somewhat or very satisfied), with attitudes toward surgery unchanged.

CONCLUSIONS

For patients with refractory plantar heel pain, ultrasound-guided denervation of the MCN can potentially improve symptoms, although efficacy needs assessing in comparative studies.

CLINICAL RELEVANCE

Ultrasound-guided denervation of the MCN provides a further management option for patients with refractory plantar fasciosis.

Treatment of Chronic Plantar Heel Pain With Radiofrequency Neural Ablation of the First Branch of the Lateral Plantar Nerve and Medial Calcaneal Nerve Branches

From March 2012 to February 2013, 37 patients experiencing plantar heel pain for ≥6 months despite treatment with physical therapy and other conservative treatment modalities were followed up. If neurogenic heel pain originating from the first branch of the lateral plantar nerve was present, with or without the medial calcaneal nerve, diagnostic nerve blocks to these nerves were performed for confirmation. If the pain was determined to be of neurogenic origin, radiofrequency neural ablation (RFNA) was applied to the corresponding sensory nerve endings. Pain was evaluated using the visual analog scale, and patients were followed for at least one year. A total of 41 feet from 37 patients (30 [81.1%] females, 7 [18.9%] males; mean age, 50.7 ± 1.6 years; mean body mass index, 30.6 ± 0.7 kg/m(2)) were included. The mean visual analog scale scores improved significantly from 1 to 6 to 12 months after the procedure relative to before the procedure, with 88% of all patients rating the treatment as either very successful or successful at 12 months postoperatively. RFNA applied to both the first branch of the lateral plantar nerve and the medial calcaneal nerve sensory branches (16 [39%] feet) and only the first branch of the lateral plantar nerve sensory branches (25 [61%] feet) showed similarly high levels of success. Of the 41 feet, 28 [68.3%] had received extracorporeal shockwave therapy, 35 [85.4%] had received steroid injections, and 22 [53.7%] had received both extracorporeal shockwave therapy and steroid injections before RFNA as an index procedure. All were unresponsive to these previous treatments. In contrast, almost all (88%) were treated successfully with RFNA. Despite a high incidence of neurologic variations, with a precise diagnosis and good application of the technique using the painful points, chronic plantar heel pain can be treated successfully with RFNA.

Analysis of Pressure Pain Hypersensitivity, Ultrasound Image, and Quality of Life in Patients with Chronic Plantar Pain: A Preliminary Study

OBJECTIVES

To evaluate widespread pressure pain in patients with chronic plantar heel pain compared with that in healthy controls and to investigate the differences in ultrasound imaging and quality of life between these two groups.

METHODS

A total of 22 patients (11 female) with chronic plantar heel pain and the same number of healthy patients, matched according to age and gender, were included in this pilot study. Pressure pain thresholds (PPTs) were bilaterally assessed over the calcaneus bone, the plantar fascia, the first and fifth metatarsals, the soleus muscle, the second metacarpal, and the zygapophyseal joint of C5-C6. Plantar fascia thickness was measured via ultrasound imaging. In addition, quality of life and physical function were assessed using the Short-Form 36 (SF-36) questionnaire and the Foot and Ankle Ability Measure (FAAM) questionnaire, respectively.

RESULTS

Analysis of covariance (ANCOVA) results showed significant differences in the PPTs at all points between the groups (P < 0.001), but not between sides. The PPTs were significantly lower in the patients than in the controls at all sites (P < 0.05). The results showed significant increases in fascia thickness at the calcaneus insertion (group: F = 74.172, P ≤ 0.001; side: F = 8.920, P ≤ 0.001) and the middle fascia point (group: F = 133.685, P = <0.001; side: F = 11.414, P = <0.001) on ultrasound in the patient group compared with the matched control group. The analysis also revealed that the patient group had a significantly lower score on every subscale of the SF-36 and FAAM questionnaires (all P < 0.001), except for the mental component, compared with the matched control group.

DISCUSSION

Patients suffering from chronic plantar heel pain showed widespread and bilateral hypersensitivity, increased thickness of the plantar fascia in the affected foot, and deterioration in quality of life and physical functioning compared with matched controls.

Deep massage to posterior calf muscles in combination with neural mobilization exercises as a treatment for heel pain: a pilot randomized clinical trial

BACKGROUND

Plantar heel pain syndrome (PHPS) is a common foot disorder; however, there is limited clinical evidence on which to base treatment. Repeated clinical observations indicating heel pain during heel rise and minisquat on the affected leg, involving activation of posterior calf muscles, formed the basis of this study.

OBJECTIVE

To compare deep massage therapy to posterior calf muscles and neural mobilization with a self-stretch exercise program (DMS) to a common treatment protocol of ultrasound therapy to the painful heel area with the same self-stretch exercises (USS).

METHODS

Patients with PHPS were assigned to a program of 8 treatments over a period of 4-6 weeks in a single-blind randomized clinical trial. Functional status (FS) at admission and discharge from therapy as measured by the Foot & Ankle Computerized Adaptive Test was the main outcome measure.

RESULTS

Sixty-nine patients were included in the trial (mean age 53, standard deviation (SD) 13, range 25-86, 57% women), 36 received DMS treatment and 33 with USS. The overall group-by-time interaction for the mixed-model analysis of variance (ANOVA) was found statistically significant (p=0.034), with a change of (mean (confidence interval, CI)) 15 (9-21) and 6 (1-11) FS points for the DMS and USS groups, respectively.

CONCLUSIONS

Data indicated that both treatment protocols resulted in an overall short-term improvement, however, DMS treatment was significantly more effective in treating PHPS than USS treatment.

Comparison of ultrasound-, palpation-, and scintigraphy-guided steroid injections in the treatment of plantar fasciitis

BACKGROUND

The aim of the study was to compare the efficacies of steroid injections guided by scintigraphy, ultrasonography, and palpation in plantar fasciitis.

METHODS

A total of 35 heels of 27 patients were randomly assigned to three steroid injection groups: palpation-guided (pg), ultrasound-guided (ug), and scintigraphy-guided (sg). Patients were evaluated for pain intensity before the injections and at the last follow-up of 25.3 months with a 100-mm visual analog scale (VAS).

RESULTS

There were significant improvements in plantar fascia thickness, fat pad thickness, and VAS. Among the three groups of ug-pg, ug-sg, and pg-sg there were no statistically significant differences after treatment (P = 0.017, MWU = 36.5; P = 0.023, MWU = 29.5; and P = 0.006, MWU = 13, respectively).

CONCLUSIONS

The ug, pg, and sg injections were effective in the conservative treatment of plantar fasciitis. We are of the opinion that steroid injections should be performed, preferably with palpation or ultrasonographic guidance.

A retrospective study of radiofrequency thermal lesioning for the treatment of neuritis of the medial calcaneal nerve and its terminal branches in chronic heel pain

We undertook a retrospective analysis of 75 consecutive patients with recalcitrant plantar heel pain caused by calcaneal neuritis, all who were treated with radiofrequency thermal lesioning (RTL). The median age of the cohort was 55 (range 24 to 83) years, 25 (33.3%) of the patients were male, 50 (66.7%) of the patients were female, and 15 (20%) of the patients were treated for bilateral heel pain caused by medial calcaneal neuritis. The median preoperative VAS score was 9 (range 2 to 10), whereas the median long-term postoperative VAS score was 1 (range 0 to 8), and this difference was highly statistically significant (P < .0001). Five (6.7%) of the patients experienced recurrent heel pain, over a median follow-up duration of 18 (range 12 to 36) months. Overall, 93.3% of the patients experienced satisfactory pain relief with radiofrequency lesioning for the treatment of recalcitrant plantar heel pain caused by medial calcaneal neuritis.

LEVEL OF CLINICAL EVIDENCE

2.

The use of low-energy radial shockwave in the treatment of entrapment neuropathy of the medial calcaneal nerve: a pilot study

Medial calcaneal nerve entrapment is a well-recognized cause of heel pain. In addition, the development of an amputation neuroma of the medial calcaneal nerve from prior heel surgery via an open incision on the medial aspect of the heel is a serious common postoperative complication and can be extremely difficult to treat. This preliminary pilot study demonstrates that the use of low-energy extracorporeal shockwave is safe and efficacious in the treatment of this disorder without the morbidity associated with denervation surgery, which would be one of the most common methods to treat this complicated situation. Four patients, 2 with bilateral affectation, for a total of 6 medial calcaneal nerves, had a series of treatments with low-energy radial shockwave with the Swiss DolorClast machine. All 4 patients had improvement in their pain scores, to the point that none elected surgical treatment, and there were no complications.

A review of plantar heel pain of neural origin: differential diagnosis and management

Plantar heel pain is a symptom commonly encountered by clinicians. Several conditions such as plantar fasciitis, calcaneal fracture, rupture of the plantar fascia and atrophy of the heel fat pad may lead to plantar heel pain. Injury to the tibial nerve and its branches in the tarsal tunnel and in the foot is also a common cause. Entrapment of these nerves may play a role in both the early phases of plantar heel pain and recalcitrant cases. Although the contribution of nerve entrapment to plantar heel pain has been well documented in the literature, its pathophysiology, diagnosis and management are still controversial. Therefore, the purpose of this article was to critically review the available literature on plantar heel pain of neural origin. Possible sites of nerve entrapment, effectiveness of diagnostic clinical tests and electrodiagnostic tests, differential diagnoses for plantar heel pain, and conservative and surgical treatment will be discussed.

Medial calcaneal neuropathy is associated with plantar fasciitis

OBJECTIVE

To demonstrate a method of sensory nerve conduction study (NCS) for the medial calcaneal nerve (MCN) and confirm the medial calcaneal neuropathy in patients with plantar fasciitis (PF).

METHODS

Twenty-six patients with clinical and ultrasonographic diagnosis of PF participated in the present study. An antidromic method for sensory NCS of MCN was performed in each patient and in 30 controls. The conduction latency, sensory nerve conduction velocity (SNCV) and amplitude of the sensory nerve action potential (SNAP) were measured and the correlation of the SNCV of MCN with both body weight and body mass index (BMI) was studied.

RESULTS

The mean conduction latency obtained in the MCN was greater in the PF patients than in the normal controls. Mean SNCV and SNAP amplitude of the MCN were significantly less in the PF patients than in the normal controls. Body weight and BMI were greater in PF patients than in controls. Six patients were identified as having a medial calcaneal neuropathy by using the criteria of the lowest normal values of the NCS of MCN from the normal controls.

CONCLUSIONS

Medial calcaneal neuropathy is associated with PF. The present method of sensory NCS is useful and objective in the diagnosis of the medial calcaneal neuropathy.

SIGNIFICANCE

Medial calcaneal neuropathy was confirmed by the sensory NCS of MCN and shown to be associated with PF.

Neurogenic heel pain

This article establishes a standard approach for the evaluation of patients with heel pain. With this approach, it should become easier for the physician to distinguish between neurogenic and inflammatory heel pain and to devise a more direct plan for definitive treatment.