Nonoperative management of retrocalcaneal pain with AFO and stretching regimen.

BACKGROUND: Retrocalcaneal heel pain is caused by a spectrum of etiologies all resulting in the same symptom of pain at the tendon-Achilles insertion. Several studies have reported the outcomes of operative treatment, but none have reported the outcomes or success rates of nonoperative treatment. We describe a detailed treatment algorithm and report the clinical outcomes. METHODS: One hundred thirty-five patients were prescribed a treatment regimen consisting of an AFO and stretching program and were enrolled in our prospective study. One hundred three patients completed pre- and post-treatment Foot Function Indices and were included in the analysis. The effect on FFI from clinical and radiographic factors was examined. RESULTS: Of the study population, 76% had a BMI greater than 25, 80% were older than 50 years, and 75% had an exostosis on radiographs. The mean pre-treatment FFI was 48.4 and the mean post-treatment FFI was 18.6 indicating a statistically significant improvement in function of 29.8. Neither BMI nor age had a significant effect on the magnitude of improvement; though, smokers had significantly less improvement. FFI improvement in patients with an exostosis were less than those without an exostosis. Patients with an exostosis less than 1 cm had less improvement than those with an exostosis of 1 cm or more. Patients with Types I and III exostoses had significantly less improvement in FFI compared to Types II and IV. Twelve of the 103 (11.6%) were not pleased with the results of nonoperative treatment and elected to have a procedure performed. CONCLUSION: Our study is the first to report the outcome of non operatively treated retrocalcaneal heel pain and to classify retrocalcaneal exostoses. Using our treatment algorithm, we had an 88% success rate in alleviating symptoms and avoiding surgery. Our data suggests that the use of an AFO and stretching regimen may benefit patients suffering from retrocalcaneal heel pain.

Hand ischemia caused by solitary humeral exostosis irritating the brachial artery.

A 39-year-old woman presented with ischemia of the left hand. Angiography revealed thrombosis of forearm arteries. Surgical intervention was unsuccessful. CT angiography revealed an exostosis on the distal humerus close to the brachial artery which we believe was the cause of repetitive minor trauma to the brachial artery leading to embolic occlusion of the radial and ulnar arteries. Early diagnosis of the underlying cause is the key to successful treatment of hand ischemia. For patients without risk factors for arterial occlusive disease, imaging of bony structures must be performed in order not to miss the likely cause of an insidious repetitive vascular trauma.

Trauma-induced exostosis of multiple suture lines causing partial bilateral nasolacrimal duct obstruction in a 7-year-old Thoroughbred mare.

A definitive diagnosis of extensive suture line exostoses affecting the nasofrontal, nasolacrimal, nasomaxillary, frontolacrimal, lacrimozygomatic and lacrimomaxillary suture lines in a 7-year-old Thoroughbred mare with chronic bilateral epiphora and facial deformation was achieved using standing computed tomography (CT) examinations. Positive contrast dacryocystorhinography using CT revealed partial bilateral obstruction of the nasolacrimal ducts. Minimally displaced depression fractures of the right nasal bone, the right maxillary bone and right frontal bone were also demonstrated. The cosmetic appearance of the periosteal reaction associated with the suture line exostosis and epiphora significantly improved within 3 months of diagnosis and treatment.

Mortarmen's Knee: Adult-Onset Tibial Tubercle Exostoses in 2 Infantrymen.

Two 20-year-old male patients presented together to a multidisciplinary primary care sports medicine clinic with reports of focal swelling and pain at the left anterior knee just distal to the patella. Both patients enlisted together, chose the same occupational specialty, and trained together, resulting in similar exposure to training loads. Following examination, radiographic imaging was ordered for both patients. Radiographs of both patients revealed exostosis and fragmentation, with multiple ossicles of the tibial tubercle. J Orthop Sports Phys Ther 2018;48(6):510. doi:10.2519/jospt.2018.8005.

Scuba diving and otology: a systematic review with recommendations on diagnosis, treatment and post-operative care.

Scuba diving is a popular recreational and professional activity with inherent risks. Complications related to barotrauma and decompression illness can pose significant morbidity to a diver's hearing and balance systems. The majority of dive-related injuries affect the head and neck, particularly the outer, middle and inner ear. Given the high incidence of otologic complications from diving, an evidence-based approach to the diagnosis and treatment of otic pathology is a necessity. We performed a systematic and comprehensive literature review including the pathophysiology, diagnosis, and treatment of otologic pathology related to diving. This included inner, middle, and outer ear anatomic subsites, as well as facial nerve complications, mal de debarquement syndrome, sea sickness and fitness to dive recommendations following otologic surgery. Sixty-two papers on diving and otologic pathology were included in the final analysis. We created a set of succinct evidence-based recommendations on each topic that should inform clinical decisions by otolaryngologists, dive medicine specialists and primary care providers when faced with diving-related patient pathology.

Common nail tumors.

Nail abnormalities are varied and numerous. They include warts, keratoacanthomas, onychomatricomas, fibrokeratomas, osteochondromas, tumors (ie, glomus, giant cell, Koenen's, and others), and Bowen's disease. Although the gravity of these conditions may vary, prompt diagnosis and treatment is of the utmost importance. This article discusses the most common defects associated with the nail unit and its surrounding tissue, as well as the differential diagnosis and treatment of these conditions.

Treatment of external auditory canal exostoses.

Exostoses of the external auditory canal can occur in patients living in coastal, southern California communities with a history of cold-water aquatic activities such as ocean surfing and swimming. Although most canal exostoses are asymptomatic, patients with canal obstruction greater than 80% can have recurrent episodes of external otitis and a related conductive hearing loss. In most cases, medical treatment resolves the symptomatic external otitis and related hearing loss. Patients recalcitrant to medical treatment are candidates for surgical removal of the exostoses. This report reviews the authors' surgical experience with 18 patients (27 ears) who have undergone surgical removal of exostoses. Their preferred surgical technique of transmeatal removal of exostoses with a specialized mallet and thin chisel under local anesthesia is described.

Scaphoid exostosis and radio-carpal osteoarthrosis.

We report seven patients (eight wrists) with osteoarthrosis of the wrist associated with an exostosis arising from the dorsal aspect of the scaphoid. We believe that the exostosis is secondary to impingement of the scaphoid on the radial styloid process and is a consequence rather than a cause of osteoarthrosis. Conservative management is advised.

Extracorporeal shockwave therapy (ESWT) in patients with chronic proximal plantar fasciitis.

The aim of this study was to compare the effect of extracorporeal shockwave therapy (ESWT) in patients with chronically painful proximal plantar fasciitis with a conventional conservative treatment consisting of nonsteroidal anti-inflammatory drugs, heel cup, orthoses and/or shoe modifications, local steroid injections and electrotherapy. Forty-seven patients (49 feet) with a previously unsuccessful conservative treatment of at least six months were randomized to two groups. Treatment of Group 1 (25 heels) started immediately with three sessions of ESWT (3000 shockwaves/session of 0.2 mJ/mm2) at weekly intervals. In the patients of Group 2 (24 heels) treatment was continued for 12 weeks. After this period they were treated using the protocol of Group 1. No significant difference of pain and walking time after further non-ESWT treatment (three months) was seen. Six months after ESWT pain decreased by 64% to 88% on the visual analog scale (VAS) and the comfortable walking time had increased significantly in both groups.

Heel spur syndrome. Pathomechanics and nonsurgical treatment. Biomechanics Graduate Research Group for 1988.

In this study, the authors review the multitude of suspected etiologies of heel spur syndrome, propose a new pathomechanical theory, and apply a treatment plan to 84 patients with 133 painful heels. The study investigates whether there is a common foot type to the syndrome and whether factors such as sex, age, occupation, and weight influence incidence or treatment. A subgroup is established, consisting of subjects who only received mechanical treatment, to determine if a change in foot position can relieve symptoms.

Management of heel pain syndrome with acetic acid iontophoresis.

This study was undertaken to determine the effectiveness of acetic acid iontophoresis in the treatment of heel pain. Thirty-five patients with chronic heel pain were treated with acetic acid iontophoresis over a 4-year period. Ninety-four percent of patients had complete or substantial relief of heel pain after an average of 5.7 sessions of acetic acid iontophoresis over an average period of 2.8 weeks. Heel pain levels were rated from 0 to 10, with 10 representing the most severe pain. Heel pain prior to iontophoresis treatment received an average rating of 7.5; by the end of therapy, the average rating had decreased to 1.8. At an average follow-up time of 27 months, heel pain levels averaged 0.64, indicating continued reduction in heel pain. Ninety-four percent of participants said that they would recommend acetic acid iontophoresis to someone with similar heel pain.

Long-term follow-up of heel spur surgery. A 10-year retrospective study.

A comparative retrospective study of 48 open heel spur surgeries and 20 endoscopic plantar fasciotomies was conducted involving 59 patients over a 10-year period. There was a significant reduction in heel pain at the time of follow-up (average, 3 years) for both groups. Overall, 85% of procedures were associated with patient satisfaction with the results, and patients said that they would recommend heel spur surgery for relief of severe heel pain in 94% of cases. Factors influencing the postoperative outcome, such as duration of preoperative symptoms, extent of conservative care, and obesity, are discussed.

[Shock waves in orthopedics]. / Stosswellen in der Orthopädie.

Extracorporeal shock waves have revolutionized urological stone treatment. Nowadays shock waves are widely used in orthopedics, too. This article reviews the applications of extracorporeal shock waves on bone and adjacent soft tissue. The osteoneogenetic effect of extracorporeal shock waves has been proven and can be used to treat pseudarthrosis with a success rate of around 75%. Shock waves have a positive effect in tennis and golfer's elbow, calcaneal spur, and the complex called "periarthritis humero-scapularis." The mechanism for this is not yet known, and results from large prospective and randomized studies are still lacking. However, the treatment has been performed many thousands of times. In patients in whom conservative treatment has failed surgery used to be the only choice, but its success rate barely exceeds that of shock wave therapy and surgery can still be done if shock wave therapy fails. Extracorporeal shock waves will have an impact on orthopedics comparable to its effect in urology. Scientific evaluations, professional certifications, quality assurance and reimbursement issues present great challenges.

History and mechanical control of heel spur pain.

The symptom of heel pain from heel spur syndrome has both a cause (abnormal pronation) and an effect (inflammation at the heel spur area). I believe that heel spur syndrome cause and effect can best be treated mechanically by a two-stage approach. This two-stage approach uses a different orthotic for each stage. The first stage is to prescribe an orthotic to alleviate the cause through control of abnormal pronation by posting or wedging, and also to alleviate the effect by local accommodation and shock absorption of the inflamed area. The second stage of mechanical treatment is begun after the effect (local inflammation) has subsided. This second stage consists of treatment with a rigid functional orthotic to treat only the cause. This orthotic is more durable and controlling and will therefore maintain the patient and prevent abnormal pronation from occurring. Thus, the cause of pain at the heel spur area will be eliminated. Orthotics can be a great adjunct to treatment of heel spur syndrome. But, as is the case with any other method you use to treat your patients, orthotics are only as good as the theories on which you base them. There are a variety of excellent materials and computerized methods being used today for fabrication of orthotic devices, but they are only as effective as the knowledge on which you base them. If you do not understand the etiology of the mechanical problem and do not observe what treatment is successful and the reasons behind this success, the orthotic you prescribe is not going to have a high level of success, regardless of new materials or technology. You will be like the laboratory technician who can fabricate an orthotic, but cannot predict, with any level of confidence, whether it will alleviate the mechanical problem.

Modified surgical approach for retrocalcaneal exostectomy with early return to weight bearing.

This procedure is a minimally invasive method of excising a retrocalcaneal exostosis and has been performed at the authors' facility for several years with excellent results and no incidence of Achilles tendon compromise. Postoperative recovery and return to weight bearing are accelerated compared with procedures that reflect the Achilles tendon from its insertion.

Common exostectomies of the rearfoot.

A review of literature for first metatarsocuneiform joint exostosis, accessory navicular bone, Haglund's syndrome, and os trigonum syndrome does not reveal any significant changes in the process of diagnosis and treatment. The surgical procedures are simple to perform but complications do occur that necessitate the understanding of the pathology and anatomy for each condition.

Infracalcaneal heel pain in the athlete.

Heel-spur syndrome is a condition encountered on a daily basis by those practitioners who primarily treat athletes. The authors discuss anatomy, the clinical examination, radiographic evaluation, exercise, and alternative medicines.

[Spavin in horses]. / Spat bij het paard.

The pathogenesis of bone spavin and its implications for diagnosis and therapy are reviewed. The pathogenesis of spavin can be divided into three phases, which are characterised by fibrillation of cartilage, osteolysis and ankylosis respectively. It will depend on the degree of osteolysis whether diagnostic anaesthesia should be added to standard clinical and radiological examinations. Satisfactory results of treatment in the group of patients with severe osteolysis can only be obtained by arthrodesis of the distal tarsal joints. It is expected that biomechanical investigations will provide a better understanding of the mechanical factors involved in the pathogenesis of spavin. For the time being, the only method of prevention will have to consist in strict selection and high-level rearing of the young horses.