Maybe it’s not Plantarfasciitis but Heel Fat Pad Syndrome
July 29, 2010
Do you have heel pain? And think it is Plantar Fasciitis?
Maybe not, it might be another type of heel pain called the Heel Fat Pad Syndrome.
What´s the difference between the Plantar Fasciitis and Heel Fat Pad Syndrome?
As shown in the illustration, both structures are in the same area of the heel whereas the plantar fascia (illustrated as plantar apponeurosis) is covered by the fat pad. The plantar fascia attaches at the toes and forms the medial (longitudinal) arch of the foot. It provides static support of the medial arch and dynamic shock absorption. The main functions of the fad pad is shock absorption of stress during heel strike (heel contact during walking).
While both the heel fat pad and plantar fascia can be a source for heel pain, the contributing factors, clinical signs and symptoms and management for them differ.
Plantar Fasciitis
Plantar fasciitis is an overuse condition of the plantar fascia.
Contributing factors: It is often seen in people with foot deformities e.g. flat feet (low arches) or pes cavus (high arches). This deformities can lead to an excessive strain at the fascia during walking and hence cause pain. Other risk factors which can lead to increased stress in the fascia are inappropriate or non-supportive footwear, reduced ankle mobility, obesity and work related weight bearing.
Clinical signs and symptoms: A typical clinical sign is swelling of the plantar fascia and can be confirmed by ultrasound investigations. People with plantar fasciitis classically have a gradual onset of symptoms and feel their pain more on the inner side of the heel. Further symptoms are acute tenderness of the inner side of the heel, a tight plantar fascia and pain during stretching of the fascia. Especially the first steps in the morning or after rest are painful. The pain seems to decrease after a few minutes, and returns as the day proceeds and time on the feet increases.
Management: Due to the tightness of the plantar fascia that leads to pain, treatments involve stretching and massaging to release the tight fascia and calf muscles. Other management include avoiding aggravating activities (e.g. wearing heels), cold therapy (R.I.C.E), anti-inflammatory drugs, taping to to relief pain and lastly it is crucial to strengthen calf muscles that have weakened during the pain process. Some patients who are still symptomatic after conservative treatment might need surgery.
Heel Fat Pad Syndrome
Heel fat pad syndrome is often caused by a decreased elasticity of the fat pad. A fall onto the heel from a height or chronically excessive heel strike with poor footwear can also lead to heel pain.
Contributing factors: Increased age and weight decreases the elasticity of the fat pad.
Clinical signs and symptoms: Compared to plantar fascitis, fat pad related heel pain is felt more at the outer side of the heel especially when the heel gets loaded (heel strike). MRI investigations will reveal changes in the fat pad showing signs of swelling.
Management: Treatments aimed at unloading the heel by avoiding aggravating activities. In an acute situation the R.I.C.E. rule (Rest Ice Compression Elevation) should be applied and anti inflammatory drugs are given. Further treatment includes taping, the use of a silicone gel heel pad and use of appropriate footwear.
References:
- Brukner, P & Khan, K 2007, Clinical Sports Medicine, 3rd edition, Tata McGraw Hill, Australia .
Ankle Overpronation and Injuries video
July 18, 2010
Have you wondered why overpronation (rolling inward) of your ankles can cause injuries? Click on the video to find out more.
How to prevent ankle sprains from happening … again
April 30, 2010
Have you ever wondered that maybe there is a way to change this?
Did you know that 85-90% of untreated ankle sprains will be recurrent, but with correct management after the first occurrence those number of cases can be brought down to only 35%?
What happens in an ankle sprain? Which structures are involved?
As a result of continued rolling, turning or instability of the ankle, the ability to make rapid adjustments in the position of the foot on uneven surfaces (proprioception) becomes limited. If this happens, the likelihood of a more severe ankle sprain occurring increases.
A sprain is actually a tear that occurs in the outer supportive ligaments of the ankle. As these ligaments are stretched, a critical point is reached beyond which ligaments do not return to their normal elastic function and a tear of the ligament occurs. Sprains can range from the relatively minor to completely torn ligaments where the ankle can be quite loose.
The common diagnosis for pain on the outer side of the ankle is an inversion sprain. This usually occurs when the foot lands in an awkward manner and rolls inwards, creating stress on the outside ligaments. When this stress is severe enough, an ankle sprain occurs.
There are three major ligaments attached to the outside of the ankle: the anterior and the posterior talofibular ligaments (ATFL and PTFL), and the calcaneofibular ligament (CFL). The ATFL is the most common ligament to sprain due to the mechanics and the limited support at the front of the ankle.
The other type of ankle sprain is an eversion sprain for pain on the inner side of the ankle. This happens when the foot is twisted outwards. The inner ligament, called the deltoid ligament, is over-stretched.
What can I do after spraining my ankle?
If you are unable to put weight or walk on it, you may have a small fracture. It is advisable for you to get it X-rayed. However, if you feel like you simply rolled over the ankle and putting weight on it hurts a little, apply RICE (Rest, Ice, Compression and Elevation) immediately. Head home and avoid walking on it as much as possible. Fill a wet thin towel with crushed ice or with a bag of frozen peas, and apply to the painful area for 10-15 minutes. Do not apply ice directly to your skin for more than five (5) minutes as it can cause cold-burns. Keep this up every 2-3 hours for the first 48 hours. This will help to minimize pain and control swelling in the area, limiting the extent of damage to the ankle.
For the ligaments to heal the ankle needs to be immobilized with either a cast or a boot. For minor sprains a brace can be applied to the ankle. Make sure it is tight enough to stop the swelling from going down into your ankle but not enough to make your toes turn blue. However, remember to take it off at night but put it back on even before you leave your bed. Keep your foot elevated at night by placing pillows underneath the affected foot to give you just enough elevation to sleep pain-free. Foot pumping exercises (continuously bending and pointing your foot out) are also especially useful when the foot is elevated to help push the fluid away from you and back to your heart. Strictly adhere to the RICE regiment for another 2-3 days or until the swelling is about 75% gone.
How do I prevent a recurrence?
If this is not the first time you have sprained the ankle, the bad news is that once a ligament has been overstretched and not taken care of, it loosens and will never go back to its original length. Not only do ligaments hold bones together, but they also part of your balance-control system by sending messages to your muscles (via the brain), telling them how to react to maintain your balance and prevent excessive movement
The basic philosophy of any rehabilitation programme is to retrained your ligaments to sense and send the required balance signals and strengthen the muscles. This restores and improves the balance around your ankle to help prevent recurring sprains and protect it from the stresses of everyday life.
A physiotherapy rehabilitation treatment programme may include:
1. Therapeutic ultrasound would be administered to promote healing and decrease in pain.
2. Soft tissue massage to aid lymphatic drainage and remove any residual swelling.
3. Individualised exercise programme which may include:
a. Calf stretch alphabet exercises – moving the ankle in multiple directions by drawing alphabets in lowercase and uppercase motions.
b. Isometric strengthening exercises, such as pushing against an immovable object (e.g. wall or floor) or with the unaffected foot, can begin.
c. Balancing exercises such as standing on your affected leg and try to hold your balance. You will probably notice at first that your injured foot is much more wobbly, which will get better with practice.
Finally, your physiotherapist would also work closely with you to plan a proper activity based training programme to get you back to sport or normal daily activities. You can follow this whole recipe for old recurrent sprains.
Heel Ergonomics – Part II
February 3, 2010
This interview continues from Handbag Ergonomics – Part I
MCR: Can high-heeled shoes change the way a person walks?
Flickr
MCR: Most shoes stores these days sell a lot of high-heeled shoes and wedges, what are the potential health dangers if they are worn for too long and too often?
Cheryl: Ankle and foot injuries while wearing high heels/ stiletto shoes are commonly reported. Commonly high-heel related injuries are calf sprains, twisted ankles and injuries from falls. Wearing high heels long term can seriously harm the feet by damaging the tendons in the heel and causing blisters, bunions, corns and calluses which some of them may even require surgery. Other conditions such as hammertoes, ingrown toenails and ankle and knee joint pains. Heel pains such as inflammation of the plantar fascia (bottom connective tissue of the foot) or plantar fasciitis are very common too.
MCR: What is the most serious scenario that can happen?
Cheryl: Fractures of the ankle or foot on falling and complete tear of ankle ligaments which requires a cast or ankle reconstruction operation to heal. Other more serious injuries that can be sustained on falling can be trauma to the head and shoulder fractures and strain. On a long term basis, research shows that wearing high heeled shoes regularly causes long-term health problems such as a distortion of the lower spine and arthritis in the knees which can lead to postural spinal stenosis and rapid degeneration of the lower spine (also known as lumbar spondylosis) leading to chronic low back pain and/or numbness or any other sensation changes in the legs.
MCR: What advice on choosing shoes?
Cheryl: There are no hard and fast rules about it, but it is recommended that high heel wearers take sensible precautions when going out in high heels or new and unfamiliar shoes in order to reduce injury. These include wearing shoes with ankle straps to help hold ankle and feet in place, making sure your shoes are properly fitted (size-wise), switching to flats during the day to give your calf muscles a break, and placing appropriate measures in shoes (i.e. heel pads, corn pads) to minimise the chance of blisters and painful friction.
MCR: How can physiotherapy help a person with heel pain?
Cheryl: Heel pain can be a result of bad walking posture/gait pattern, excessive walking and running (overtraining), wearing high heels frequently and/or muscle imbalance of the leg (hip, knee and ankle). Depending on the nature of the injury, be it a sprain or an accumulative stress related injury, physiotherapy help by applying various strategies in the reducing the stiffness, pain and discomfort in joints or muscles affected. Strategies include manual techniques, such as joint mobilization and manipulation, deep friction massage, stabilization exercises and electrotherapy i.e. ultrasound therapy. Should wearing heels be required on the job, the physiotherapist may make recommendations on the footwear, and advise on posture correction and specific muscle strengthening for injury prevention. Nevertheless, treatment is always more effective if the problem is detected and treated early as chronic problems (more than 3 months) have poorer treatment results. Therefore, if the pain does not resolve within 3-7 days and seems to get worse, it is time to make an appointment with your physiotherapist.
MCR: Besides heavy bags and high heels, what are the other potential fashion health hazards?
Cheryl:
Badly Fitting Bras
Studies have shown that as many as 90% of women are wearing the wrong bra size, many still hanging on to the same bra size they were fitted for years ago – irrespective of growing, losing weight or having children. Wearing the wrong bra could lead to shoulder tension, chest/ breathing restriction, headaches and chest and upper back pain. If the bra is too loose, it is not supportive enough and if too tight and restrictive, it can lead to restrictions in breathing normally, upper back pain and reduction of spinal movement.
Tight Pants/jeans
The trend for skinny jeans, hipsters/ low riding jeans tend to restrict movement and can also cause bad posture, changing the alignment of the spine. The tight, low riding jeans/ trousers can squeeze a sensory nerve under the hip bone, known as the femoral nerve, and cause a tingling sensation in the thighs (pins and needles) also called paresthesia.
Tendon Disorders: Inflammation and Degeneration
January 8, 2010
One common form of musculoskeletal injury is tendon-related disorders like tennis elbow and Achilles tendonitis. Your tendon is the connector that transfers power from your muscle generators to your skeletal structure to create movement. Under normal circumstances, healthy tendons glide easily and smoothly as the muscles contract. When tendons are injured, they cause pain, especially during movement. Read more
Orthotics for Achy Feet
August 16, 2009
"Dear Sir, I am a lecturer and an avid, regular sports player. My feet aches every week and I go for regular foot massages. I did an analysis on my feet during one of the orthotic analysis booths at some shopping centre which reported I have high arch and pronation. I wonder what can be done to correct that and reduce my achiness? " - Mr Ho
How to tell the difference between an ankle sprain and a fracture
July 27, 2009
This is a brief video on how to tell the difference between an ankle sprain and an ankle fracture. If you are thinking of taking an X-ray to confirm if it is a fracture, the Ottawa Ankle Rules has a guideline to check if you need an x-ray.
Simple Exercises For Plantar Fasciitis Sufferers
June 26, 2009
In an earlier post, we discussed on what plantar fasciitis is about, including the causes, symptoms and treatment options available. If you think you might be sufferring from plantar fasciitis, read on and find out more about the exercises that you can do to help ease the pain in your foot!
Plantar Fasciitis – Pain In The Heel!
June 17, 2009
What is plantar fasciitis?
Plantar fasciitis is a term given for the painful and inflamed flat, fibrous band of tissue (also known as the plantar fascia or plantar aponeurosis) that connects your heel bone to your toes. The fascia acts as a shock absorber and supports the arch of the foot. With plantar fasciitis, there is an excessive strain placed on the fascia. This excessive strain causes tiny tears in the plantar fascia exceeding the body’s capacity to recover, resulting in inflammation. In turn, this causes weakness, irritation, swelling and pain along the plantar fascia, especially in weight-bearing activities.
Ankle Replacement Surgery
June 9, 2009
An ankle replacement surgery is where the joints of the ankle are fitted with a prosthesis or an implant to replace the existing worn out joints. It is usually recommended for the elderly and relatively inactive person as one of the major complication from such a surgery is loosening of the ankle joint due to overuse. After the surgery, you will be placed on a cast to protect the joint for a period of 6-12 weeks before you can gradually put weight on it. An ankle replacement can generally last 5 – 10 years depending on the activity level of the patient.
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