[Diagnostics of polyneuropathies]. / Diagnostik bei Polyneuropathien.

The diagnosis of polyneuropathy (PNP) is based on the anamnesis and description of complaints of the patient and clinical findings. The type of distribution as well as known diseases and drug toxic factors can provide indications. Electromyography and electroneurography can be used to differentiate between axonal and demyelinating PNP. The laboratory examinations are initially directed towards frequent and treatable causes. These are then expanded depending on the suspected diagnosis. Analysis of cerebrospinal fluid (CSF) is facultative and should be carried out when there is a suspicion of a certain form of PNP with CSF findings indicative of the diagnosis. Nerve biopsy is indicated when the etiology of a severe or progressive PNP cannot be clarified by less invasive means and can have consequences for the treatment. A genetic investigation can be meaningful with a positive family anamnesis or with typical signs of hereditary PNP. Depending on the neuropathy and context, the diagnostic approach is structured differently. The special diagnostics for small fiber neuropathy and amyloid neuropathy as well as for diabetes and alcohol abuse are dealt with in detail in this article. Numerous cases of polyneuropathy remain unexplained and regularly have a favourable prognosis.

Comparison of tactile sensitivity measured with a new digital esthesiometer (Beam Test) relative to Semmes-Weinstein monofilament analog esthesiometer.

The assessment of tactile sensitivity uses many tests, of which monofilaments are considered the best. The aim of this study was to develop a tactile sensitivity test, similar to the monofilament test, which eliminates the error risk related to manipulations by the observer, and to establish a correspondence scale. We studied 29 healthy subjects (18 women and 11 men) with a mean age of 27.8 years. The Semmes-Weinstein monofilament (SWM) analog esthesiometer and a digital beam esthesiometer (DBE) were used. We evaluated the tactile sensitivity threshold on the fingertip of each subject's dominant index using the SWM and the DBE. The DBE test consisted of applying the index against the tip of the beam. During a cycle of four elevations/depressions, the subject would press a button each time he/she felt pressure. The test was repeated three times. The screen displayed an average force value between 0 and 200 allowing the result to be expressed in grams (g). The minimum perceived force was 0.06656g (0.023, 0.166) on average with the SWM test and 0.51773g (0.4824, 0.8062) with the DBE test. Our results confirm the DBE test suppresses the observer's manipulations and that a SWM correspondence scale can be established. With the DBE test, the normal sensation ranged from 0.4824g to 0.757g and light touch decreased from 0.758g to 0.8062g. The threshold value of pathological tactile sensitivity was 0.8063g. The DBE test could therefore be used for preventive diagnosis of carpal tunnel syndrome in occupational medicine.

Tactile sensitivity thresholds for the radial hemi-pulp of the index: A comparison between the Semmes-Weinstein and Cochet-Bonnet tests in 25 healthy subjects.

The purpose of this work was to determine whether the Cochet-Bonnet (CB) corneal sensitivity test has a lower cutaneous pulp sensitivity threshold than the Semmes-Weinstein (SW) monofilament test. Tactile sensitivity thresholds for the radial hemi-pulp of the index finger of 25 healthy adult subjects aged 30 years on average were measured using SW and CB esthesiometers. The sensitivity threshold of the radial hemi-pulp of the index was lower with the CB test than with the SW test. The sensitivity and specificity of the CB test on palm wounds still needs to be determined to rule out nerve damage.

Mobile phone generated vibrations used to detect diabetic peripheral neuropathy.

BACKGROUND: In the current United Kingdom population the incidence of diabetic peripheral neuropathy is increasing. The presence of diabetic neuropathy affects decision making and treatment options. This study seeks to evaluate if the vibrations generated from a mobile phone can be used to screen patients for diabetic peripheral neuropathy. METHODS: This study comprised of 61 patients; a control group of 21 patients; a lower limb injury group of 19 patients; a diabetic peripheral neuropathy group of 21 patients. The control and injury group were recruited randomly from fracture clinics. The diabetic peripheral neuropathy group were randomly recruited from the diabetic foot clinic. The 61 patients were examined using a 10g Semmes-Weinstein monofilament, a 128Hz tuning fork and a vibrating mobile phone. The points tested were, index finger, patella, lateral malleoli, medial malleoli, heel, first and fifth metatarsal heads. RESULTS: The most accurate location of all the clinical tests was the head of the 1st metatarsal at 0.86. The overall accuracy of the tuning fork was 0.77, the ten gram monofilament 0.79 and the mobile phone accuracy was 0.88. The control group felt 420 of 441 tests (95%). The injury group felt 349 of 399 tests (87%). The neuropathic group felt 216 of 441 tests (48%). There is a significant difference in the number of tests felt between the control and both the injury and neuropathic groups. p<0.0001 using N-1 Two Proportion Test. CONCLUSION: A mobile phone is an accurate screening tool for diabetic peripheral neuropathy. The most accurate location to test for diabetic peripheral neuropathy is the head of the 1st metatarsal. Screening for diabetic peripheral neuropathy in the index finger and patella were inaccurate. An injury to the lower limb affects the patient's vibration sensation, we would therefore recommend screening the contralateral limb to the injury. LEVEL OF EVIDENCE: This study represents level II evidence of a new diagnostic investigation.

Characterization of long-term gait deficits in mouse dMCAO, using the CatWalk system.

Evaluation of functional outcome is widely used across species to assess the recovery process following various pathological conditions, including spinal cord injury, musculo-skeletal injury, mithochondrial disease, neuropathic cancer, Huntington's disease, chronic pain, cortical lesion, and olivocerebellar degeneration among others. The Stroke Therapy Academic Industry Roundtable (STAIR) recommends multiple endpoints for behavioral studies in pre-clinical stroke research, to demonstrate their clinical relevance. One of the more challenging tasks in experimental stroke research is measuring long-term functional outcome in mice. It is, however, becoming more important, since transgenic mice are increasingly used for modeling human neurological disorders. Using CatWalk, we characterized long-lasting gait/locomotion deficits following mouse distal middle cerebral artery occlusion (dMCAO). The post-dMCAO assessment was performed at 7, 14, 21, and 28days after experimental ischemia. When compared to sham-operated mice, dMCAO animals displayed a statistically significant decrease in Spatial parameters (such as Paw Area), while the Temporal parameters (Stand, Initial and Terminal Dual Stances) were significantly increased for three weeks after surgery. Kinetic parameters were significantly decreased in dMCAO animals at 7days after dMCAO. The Interlimb coordination group of parameters displayed the strongest deficits at 21days. While CatWalk variables were altered in all paws, the degree of change was greatest for the parameters measured from the Right Front Paw (contralateral to the lesion). All parameters measured in dMCAO and Sham-operated groups reached similar levels at four weeks after the experimental insult, which reflects a spontaneous post-ischemic recovery. Based on our investigation, we conclude that CatWalk represents a relevant and sensitive analysis, which allows long-term characterization of animal functional recovery in the dMCAO model of experimental ischemia.

Prevalence of leprous neuropathy determined by neurosensory testing in an endemic zone in Ecuador: Development of an algorithm to identify patients benefiting from early neurolysis.

The success of a microneurosurgical intervention in leprous neuropathy (LN) depends on the diagnosis of chronic compression before irreversible paralysis and digital loss occurs. In order to determine the effectiveness of a different approach for early identification of LN, neurosensory testing with the Pressure-Specified Sensory Device™ (PSSD), a validated and sensitive test, was performed in an endemic zone for leprosy. A cross-sectional study was conducted to analyze a patient sample meeting the World Health Organization (WHO) criteria for Hansen's disease. The prevalence of LN was based on the presence of ≥1 abnormal PSSD pressure threshold for a two-point static touch. A total of 312 upper and lower extremity nerves were evaluated in 39 patients. The PSSD found a 97.4% prevalence of LN. Tinel's sign was identified in 60% of these patients. An algorithm for early identification of patients with LN was proposed using PSSD testing based on the unilateral screening of the ulnar and deep peroneal nerves.

Selecting a Test for Leprous Neuropathy Screening.

BACKGROUND: Worldwide, leprosy represents a significant cause of disability due to progressive neurological impairment. Screening for leprous neuropathy is performed with Semmes-Weinstein monofilament (SWM) or ballpoint pen testing (BPT), which results in underreporting of its prevalence. The Pressure-specified sensory device (PSSD; Sensory Management Services, LLC, Baltimore, MD) is a sensitive, noninvasive, portable, neurosensory instrument, which has not been field-tested for leprosy screening. Early identification of leprous neuropathy would permit early antibiotic treatment to prevent contagion and early microsurgical neurolysis. METHODS: A prospective, clinical diagnostic, cross-sectional study screened a consecutive sample of patients for leprous neuropathy in the leprosy-endemic province of Los Ríos, Ecuador. Patients meeting the World Health Organization criteria for leprosy and complaining of neuropathy symptoms were classified as leprous neuropathy patients. Patients without any signs of leprosy were used as normal controls. Bilateral ulnar nerve screening with the PSSD, SWM (0.07, 0.4, 2, 4, 10, and 300 g), and BPT was performed in all patients. Sensitivity and specificity were calculated and compared across tests. A total of 71 patients (142 nerves) were evaluated. RESULTS: Compared with the 10 g SWM and the BPT, the PSSD was found to have significantly higher sensitivity (78.3 vs. 0% with p < 0.001, for both) with comparable specificity (97.8 vs. 100% with p > 0.999, for both). Compared with the 0.07 g SWM (lightest filament in our series), the PSSD showed better sensitivity (78.3 vs. 65.2%, p = 0.514) and significantly higher specificity (97.8 vs. 51.1%, p < 0.001). CONCLUSIONS: The PSSD provides superior diagnostic accuracy for detecting leprous neuropathy as compared with SWM and BPT.

Utilization of a novel digital measurement tool for quantitative assessment of upper extremity motor dexterity: a controlled pilot study.

BACKGROUND: The current methods of assessing motor function rely primarily on the clinician's judgment of the patient's physical examination and the patient's self-administered surveys. Recently, computerized handgrip tools have been designed as an objective method to quantify upper-extremity motor function. This pilot study explores the use of the MediSens handgrip as a potential clinical tool for objectively assessing the motor function of the hand. METHODS: Eleven patients with cervical spondylotic myelopathy (CSM) were followed for three months. Eighteen age-matched healthy participants were followed for two months. The neuromotor function and the patient-perceived motor function of these patients were assessed with the MediSens device and the Oswestry Disability Index respectively. The MediSens device utilized a target tracking test to investigate the neuromotor capacity of the participants. The mean absolute error (MAE) between the target curve and the curve tracing achieved by the participants was used as the assessment metric. The patients' adjusted MediSens MAE scores were then compared to the controls. The CSM patients were further classified as either "functional" or "nonfunctional" in order to validate the system's responsiveness. Finally, the correlation between the MediSens MAE score and the ODI score was investigated. RESULTS: The control participants had lower MediSens MAE scores of 8.09%±1.60%, while the cervical spinal disorder patients had greater MediSens MAE scores of 11.24%±6.29%. Following surgery, the functional CSM patients had an average MediSens MAE score of 7.13%±1.60%, while the nonfunctional CSM patients had an average score of 12.41%±6.32%. The MediSens MAE and the ODI scores showed a statistically significant correlation (r=-0.341, p<1.14×10⁻5). A Bland-Altman plot was then used to validate the agreement between the two scores. Furthermore, the percentage improvement of the the two scores after receiving the surgical intervention showed a significant correlation (r=-0.723, p<0.04). CONCLUSIONS: The MediSens handgrip device is capable of identifying patients with impaired motor function of the hand. The MediSens handgrip scores correlate with the ODI scores and may serve as an objective alternative for assessing motor function of the hand.

Screening for peripheral neuropathies in children with diabetes: a systematic review.

BACKGROUND AND OBJECTIVE: Although guidelines for the management of children with type 1 diabetes include recommendations to screen for diabetic peripheral neuropathies (DPN), the research into the diagnostic utility of screening methods has not been systematically reviewed. The goal of this study was to summarize the findings with regard to the diagnostic accuracy of the Semmes-Weinstein monofilament and the Rydel-Seiffer tuning fork in detecting DPN in children and adolescents compared with the gold standard nerve conduction studies. METHODS: Based on a PubMed search (conducted on April 26, 2013) and secondary searching, we identified 72 articles for review. We included studies that: (1) assessed DPN with the gold standard nerve conduction studies; (2) used noninvasive screening for DPN (monofilament, tuning fork, or biothesiometer); and (3) were performed in the relevant population (children with diabetes). Five articles met these criteria. Study quality was assessed by using the revised Quality Assessment of Diagnostic Accuracy Studies criteria. Heterogeneous methods precluded a formal meta-analysis of effects. RESULTS: Diagnostic accuracies were heterogeneous for the different screening methods. Sensitivities ranged from 1% to 19% for the tuning fork (3 studies); from 61% to 80% for the biothesiometer (2 studies); and from 19% to 73% for the monofilament (2 studies). CONCLUSIONS: Data show extremely low diagnostic utility for standard screening methods (tuning fork and 10-g monofilament) but acceptable utilities for biothesiometry and finer (1 g) monofilaments. Data on the diagnostic utility should be used to inform national and international guidelines on diabetes management.

Management of intraneural fibro-lipoma of the median nerve and the role of Pressure-Specified Sensory Device (PSSD) for the patient's motor and sensorial evaluations.

AIM: The intraneural fibro-lipoma is a benign, uncommon tumor which is characterised with infiltration of the epineurium and perineurium by fibrofatty tissue. The preoperative diagnosis is difficult. However, the Pressure-Specified Sensory Device (PSSD) may support identifying the earliest stages of intraneural fibro-lipoma when traditional electrodiagnostic testing will not be able to detect a change in peripheral nerve function. MATERIAL AND METHODS: Five patients (3 male, 2 female, age 23-53; mean 41 years) with intraneural fibro-lipoma were operated on. Grip strength, pinch strength and sensorial functions were assessed in all patients before surgery and at the end of the follow-up period by PSSD. RESULTS: The patients were followed-up for 7 to 24 months (mean; 12 month). All patient's condition improved dramatically following the operation and all patients had total relief of pain and paresthesia. CONCLUSION: The decompression of intraneural fibro-lipoma of the nerve with limited excision and epineurotomy without sacrificing the main nerve and its branches is the ideal surgical procedure. We recommend the use of PSSD in the investigation of patients with peripheral nerve compression, and chronic unusual volar forearm and wrist swelling. PSSD is an important tool for pre-operative evaluation and diagnosis of intraneural fibro-lipoma.

Quantitative evaluation of neurosensory disturbance after bilateral sagittal split osteotomy using Semmes-Weinstein monofilaments: a systematic review.

PURPOSE: To evaluate neurosensory disturbance of the inferior alveolar nerve, after bilateral sagittal split osteotomy, from before surgery to 1 year postoperatively, by quantitatively evaluating published data using Semmes-Weinstein monofilaments. MATERIALS AND METHODS: A literature search was conducted by use of PubMed, EMBASE, Scopus, Web of Science, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and the Cochrane Library in June 2012. The related citations function in PubMed, reference lists, and authors' names were used to expand the search. From each included study, study and sample characteristics were extracted, as were results. The main outcome was the lightest pressure the patient could discern at 1 month and at 1 year after the osteotomy procedure, in comparison with before surgery. RESULTS: Of the 3,107 articles initially identified, 7 were chosen according to the preset inclusion and exclusion criteria. The results from the studies could not be combined for the purpose of a meta-analysis because of the lack of standardization. Only 2 studies provided data that allowed an estimation of average detectable applied force to be carried out. Before surgery, the lowest detectable threshold corresponded to a mean of 0.07 to 0.16 g. At 1 month after surgery, the lowest detectable threshold averaged 6 g, and at 1 year after surgery, the mean value was 0.16 to 0.4 g. CONCLUSIONS: After bilateral sagittal split osteotomy, at 1 month after surgery, the sensory threshold increases approximately 35- to 85-fold compared with the presurgery threshold. Within 1 year, the threshold normally decreases almost to presurgery levels, representing 96% to 98% sensory recovery. Studies should aim to quantitatively use the Semmes-Weinstein monofilament method and standardize the presentation of results.

[Diagnosis of neurogenic bladder dysfunction]. / Diagnostik der neurogenen Blasenfunktionsstörung.

Patients with congenital and acquired neurogenic bladder dysfunction due to central and peripheral nervous lesions are significantly limited in their daily lives. The neurogenic dysfunction of the bladder and lower urinary tract are often misinterpreted and later fed to a diagnosis. Without therapy severe complications, including renal damage, could be the consequence in the follow up. Therefore, dedicated diagnostics have to be done to recognize the different disorders and to determine the specific therapy. For these patients a lifelong bladder monitoring and neuro-urological management is necessary. This article describes techniques of neuro-urological testings and the interpretation in case of neurogenic disorders.

The relationship between numbness, tingling, and shooting/burning pain in patients with chemotherapy-induced peripheral neuropathy (CIPN) as measured by the EORTC QLQ-CIPN20 instrument, N06CA.

BACKGROUND: Chemotherapy-induced peripheral neuropathy (CIPN) is characterized by numbness, tingling, and shooting/burning pain. This analysis was performed to describe the relationship between numbness, tingling, and shooting/burning pain in patients with CIPN, as reported using the EORTC QLQ-CIPN20 (CIPN20). METHODS: Baseline CIPN20 data were provided for all patients on a prospective trial designed to treat patients with bothersome CIPN. Baseline frequencies for the items on the CIPN20 are primarily described by descriptive statistics and histograms, with correlational analyses between individual items. RESULTS: A majority of the 199 patients accrued to this study reported "quite a bit" to "very much" numbness (57%) or tingling (63%) in the hands compared to "a little" or "not at all" (numbness (43%), tingling (38%)). Fewer patients reported "quite a bit" to "very much" shooting/burning pain in the hands (18%). Numbness and tingling in the hands were highly correlated (r = 0.69), while neither were highly correlated with shooting/burning pain. Similar results were observed in the feet. More severe ratings for tingling and shooting/burning pain were ascribed to the lower extremities, as opposed to the upper extremities. CONCLUSIONS: In patients with CIPN, severe sensory neuropathy symptoms (numbness, tingling) commonly exist without severe neuropathic pain symptoms (shooting/burning pain), while the reverse is not common. Symptoms in the feet should be evaluated distinctly from those in the hands as the experience of symptoms is not identical, for individual patients, in upper versus lower extremities.

Evolución de los signos cerebelosos, la paratonía y las sincinesias en el niño / Evolution of cerebellar signs, the paratonia and the child synkinesias

Objetivo: estudiar a través del examen neurológico evolutivo, la maduración de los signos cerebelosos, la paratonía y las sincinecias en el niño. Método: se realizó un estudio de tipo transversal, examinándose niños de 4 a 12 años de edad, de ambos sexos, de escuelas públicas de Montevideo, entre octubre 2006-mayo 2008. Resultados: se examinaron 330 niños, 178 varones y 152 niñas. La paratonía en maniobra de caída del brazo, estuvo presente en el 70% a los 4 años y en el 17% a los 11 años. A los 7 años el 100% de los niños lograron el equilibrio estático en un pie y el 92.5% el equilibrio en el salto en un pie. La marcha punta-talón la lograron el 96.2% de los niños de 6 años de edad. El 79% de los niños de 7 años lograron la metría en la maniobra índice-nariz. La diadococinesia en la maniobra palma-dorso fue lograda en el 100% de los niños de 6 años de edad y la maniobra de marionetas en el 100% de los niños de 9 años. Las sincinesias de imitación estuvieron presentes en el 80% a los 4 años y menos del 20% a los 11 años. La maniobra de oposición de dedos al pulgar la lograron el 92,5% de los niños de 8 años de edad. Conclusiones: se constata que el desarrollo motriz presenta etapas secuencialmente ordenadas, donde los cambios más significativos en la maduración de los sistemas motores ocurre entre los 5 y 6 años de edad.

[Diagnosis of neuropathic pain]. / Diagnostik bei Neuropathischen Schmerzen.

Neuropathic pain arises from damage, or pathological change, in the peripheral or central nervous system. As such, the term neuropathic pain represents a varying set of symptoms rather than a single diagnosis. There is no diagnostic gold standard for neuropathic pain and so making a diagnosis is based on clinical judgement. The essential elements of this process are to identify painful symptoms and a clinical history that all match a neuro-anatomical or dermatomal pattern. Abnormal responses to nerve damage account for many of the clinical features of neuropathic pain. Painful symptoms arising in an area of altered sensation (numbness or hyper-excitability) is the hallmark of neuropathic pain. Cardinal features are spontaneous pains (pain arising without stimulus) and abnormal responses to non-painful (allodynia) or painful stimuli. The diagnostic work-up includes screening tools such as pain questionnaires and pain drawings as well as information on the history of the disease and a detailed clinical-neurological examination. Bedside examination is straightforward. The aim is to identify altered sensation in the painful area and so responses should be compared with a non-painful adjacent or contra-lateral area. A combination of characteristic painful symptoms in an area of altered sensation on bedside testing is usually enough to make a diagnosis of neuropathic pain. When doubt arises, more detailed examination using Quantitative Sensory Testing or conventional electrophysiology can be helpful.

A new device to quantify tactile sensation in neuropathy.

OBJECTIVE: To devise a rapid, sensitive method to quantify tactile threshold of finger pads for early detection and staging of peripheral neuropathy and for use in clinical trials. METHODS: Subjects were 166 healthy controls and 103 patients with, or at risk for, peripheral neuropathy. Subjects were screened by questionnaire. The test device, the Bumps, is a checkerboard-like smooth surface with 12 squares; each square encloses 5 colored circles. The subject explores the circles of each square with the index finger pad to locate the one circle containing a small bump. Bumps in different squares have different heights. Detection threshold is defined as the smallest bump height detected. In some subjects, a 3-mm skin biopsy from the tested finger pad was taken to compare density of Meissner corpuscles (MCs) to bump detection thresholds. RESULTS: The mean (±SEM) bump detection threshold for control subjects was 3.3 ± 0.10 µm. Threshold and test time were age related, older subjects having slightly higher thresholds and using more time. Mean detection threshold of patients with neuropathy (6.2 ± 0.35 µm) differed from controls (p < 0.001). A proposed threshold for identifying impaired sensation had a sensitivity of 71% and specificity of 74%. Detection threshold was higher when MC density was decreased. CONCLUSIONS: These preliminary studies suggest that the Bumps test is a rapid, sensitive, inexpensive method to quantify tactile sensation of finger pads. It has potential for early diagnosis of tactile deficiency in subjects suspected of having neuropathy, for staging degree of tactile deficit, and for monitoring change over time.

A comparison of neurosensory alteration and recovery pattern among different types of orthognathic surgeries using the current perception threshold.

OBJECTIVE: The objective of this study was to compare postsurgical neurosensory alteration and recovery patterns among different nerve fiber types and orthognathic surgeries by measuring current perception thresholds (CPT). STUDY DESIGN: CPTs of 186 patients who underwent various orthognathic surgeries (Le Fort I or II, bilateral sagittal split [BSSRO] or intraoral vertico-sagittal [IVSRO] ramus osteotomy with or without genioplasty) were measured at 2000, 250, and 5 Hz, assessing 3 different nerve fiber types before surgery and at 3, 6, and 12 months after surgery. RESULTS: CPTs were highest at 3 months postsurgery and gradually returned to presurgical levels until 12 months postsurgery in most cases. CPT at 2000 Hz showed the largest amount of increase. Le Fort I and IVSRO caused less neurosensory alteration compared with Le Fort II and BSSRO, respectively. CONCLUSION: Our data provide nerve recovery patterns following various orthognathic surgeries that may be applied to evaluating the patient's severity and recovery of nerve damage.

Extension of normal values on sensory function for facial areas using clinical tests on touch and two-point discrimination.

The threshold value of a sensory test provides a numerical measure of the sensory function. In order to decide whether a threshold value from an affected site indicates 'abnormal' sensory function, it can be compared with normal values from a healthy control population. The aim of this study was to extend current information on normal values for static light touch and static two-point discrimination for facial sites. Using simple hand-held devices, 95% upper limits of confidence intervals of threshold values were determined for facial sites other than those studied previously and for a large sample of 100 healthy subjects. The MacKinnon-Dellon Disk-Criminator and the Aesthesiometer were used to measure novel normal values of two-point discrimination. As threshold values for two-point discrimination from the Aesthesiometer were similar to those obtained using the Disk-Criminator, the use of the Aesthesiometer might not be indicated. Apart from the Pressure Specified Sensory Device (a device with pressure control), Semmes-Weinstein nylon monofilaments and the Disk-Criminator are useful devices for studying sensory function, in particular under clinical test conditions in which easy and fast application are advantageous.

Technique for determining when plantar heel pain can be neural in origin.

The surgeon doing microsurgery will encounter problems related to the heel not only in terms of how to reinnervate the transferred tissue, but also in patients presenting with heel pain. While most heel pain is thought to be related to the plantar fascia arising from the calcaneus, conceptually heel pain can be of neural origin. The technique for documenting sensibility in the heel is described using the Pressure-Specified Sensory Device. Knowledge of calcaneal nerve sensibility can determine whether there is sufficient sensation to prevent ulceration, whether there is a nerve entrapment that would benefit from neurolysis, or whether there is a neuroma that would benefit from resection.