Diagnosis and Management of Heel Pain

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Diagnosis and Management of Heel Pain Powered By Docstoc
					CSI MUSCULOSKELETAL: VICTIMS AND CULPRITS
Anthony Beutler, MD Assistant Professor, Department of Family Medicine Uniformed Services University

PLANTAR FASCIITIS
 Epidemiology o The Most Common cause of heel pain o Studies report it affects 10% of all runners, 2 million American’s/year Pathoanatomy o Microtears of the plantar fascial aponeurosis & subsequent collagen degeneration o Is NOT an inflammatory condition, despite “-itis” suffix Diagnostic Clues o Heel pain worst with the “first step in the morning;” Dull “toothache” pain with activity o Classic point of maximum tenderness at the medial tubercle of the calcaneus (See Figure 1) DDx (See Figure 2): o Posterior Tibialis Tendonitis (blue line) o Achilles Tendinopathy (red circle) o Achilles Enthesopathy/Insertional Pain (green square) o Tarsal Tunnel Syndrome (area of red square, blue line) o Calcaneal fracture (red square) o Entrapment of medial calcaneal branch of post tibial nerve
Fig 1 – Max TTP

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Fig 2 – DDx Heel Pain

VICTIM:

 Plantar Fascia (degeneration)

TREATMENTS FOR VICTIM:

 NSAIDs – not an “-itis”  Heel pads/cups  Steroid Injection – 2nd line for pain

COMMON CULPRITS:
Tight Heel Cords Muscular Weakness Training Error Overpronation Improper Footwear

TREATMENTS FOR CULPRITS:
Achilles Stretches (See Pt. Handout) Towel Drags (See Pt. Handout) Increase Running 10% week Orthotics (start with off the shelf) www.runnersworld.com

THINGS PEOPLE SAY:
  Tight Heel Cords: 70% of people with plantar fasciitis have gastroc/soleus inflexibility (cannot passively dorsiflex past 0 deg. [90 degree ankle angle]). This can be key in disease pathophysiology. What about my Heel Spurs?: Heel spurs look impressive radiographically, but don’t seem to mean much clinically. 15-25% of asymptomatic people have them; many plantar fasciitis sufferers do not. Heel spurs indicate that plantar fasciitis may be causing heel pain; the spurs are not the pain source. “-itis” ≠ NSAIDS: Plantar fasciitis is NOT an inflammatory process. Hence NSAIDs, steroids, and other anti-inflammatory treatments may (or may not!) control pain, but do not affect disease process.

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EVIDENCE-BASED TREATMENTS:  First-Line Treatments o Stretching and Strengthening Exercises (LOE B) – See Patient Handout Sheets o Orthotics in select populations (LOE B) o ICE for pain relief  Second-Line Treatments o Steroid injections – short term relief (LOE B) o Night Splints – for pain over 6 months (LOE B) o Custom versus Off the Shelf Orthotics (LOE C) o Surgery – probably effective, but only refer after 6-12 months of treatment failure  No Studies to Support or Refute o NSAID’s – but remember that plantar fasciitis is non-inflammatory  Pain control only  Best used only in short courses (<2 weeks)  What doesn’t work o Ultrasound (LOE B) o Laser therapy (LOE A) o Magnetic Insoles (LOE B)  References  Crawford F, Interventions for treating plantar heel pain (Cochrane Review), Cochrane Library 2008, Issue 2.  Cole C, Plantar Fasciitis: Evidence-Based Review of Diagnosis and Therapy, Am Fam Physician, December 2005. RETURN TO ACTIVITY:  Early return to activities may increase risk of plantar fascia rupture. Unclear implications.  Absolute rest has not been shown to decrease recovery time  I recommend continued activities at 50% of pre-injury level. If pain changes gait, avoid running, walking since this may predispose to other injuries.  Use the “extra time” in stretching and strengthening exercises above.  When pain begins to improve, increase activity no more than 10% per week.

ANKLE SPRAIN
 Epidemiology o Most common ER visit o Lateral Ankle most commonly affected Pathoanatomy o Anterior Talofibular Ligament (ATFL) most commonly injured. o Tibiotalar joint unstable in plantar flexion  ATFL longitudinal and susceptible to injury when ankle is plantar flexed.  Calcaneofibular ligament and posterior talofibular ligament less commonly injured Diagnostic Clues o Ottawa Ankle rules DDx: o o o o Pearls

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Foot injury Fracture Tibialis posterior or peroneal tendon injury Syndesmotic (“high ankle”) sprain

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VICTIM:

 Lateral Ankle (usually ATFL)

TREATMENTS FOR VICTIM:

 RICE  NSAIDs – impair tissue healing?  Brace – acutely improves wt. bearing, decreases re-injury. Improvements demonstrated for 3-6 months post injury!

RE-INJURY CULPRITS:
Decreased Range of Motion Decreased Strength Poor Proprioception

REHABILITATION FOR CULPRITS:
Toe Alphabet (See Pt. Handout 3) Towel Drags (See Pt. Handout 2) “Toothbrush Balance” (See Pt. Handout)

PEARLS/BRACING/RETURN TO PLAY  Medial Ankle Sprains: Be skeptical and cautious!  Crutches and limited weight-bearing for 1 week for 3rd degree sprains  Instruct patient to come back in 4-6 weeks if not better

EVIDENCE FOR BRACING:
Handoll HHG, Rowe BH, Quinn KM, de Bie R, Interventions for preventing ankle ligament injuries (Cochrane

Review), Cochrane Library 2008, Issue 2    What brace to use? Semi-rigid How long do I wear this brace? 6-12 months following injury Make sure to be doing proprioceptive rehab also!

PATELOFEMORAL PAIN
 Epidemiology o The most common cause of knee pain in patients under 40 o Unclear link with osteoarthritis, but may result in decreased activity and obesity. Obesity is a well-established cause of OA o Causes >90% of all knee pain in military primary care clinics Pathoanatomy o Biomechanical imbalance causes pain in peri-patellar structures o Possible pain generators include the anterior synovium, infrapatellar fat pad, subchondral bone, or the retinaculae Diagnostic Clues o Often bilateral o Vague pain, no discrete injury o Pain with stairs. Downstairs classically hurts more than up. o Theatre sign o Effusion, erythema very uncommon (but can happen in acute, severe overuse)

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VICTIM:

 Patelofemoral joint

TREATMENTS FOR VICTIM:

 RICE – acute treatment for chronic condition  NSAIDs – limited evidence for short term pain relief (LOE A)  Patellar Bracing/Taping – works for some; need expertise (LOE B)

“MUST FIND” COMMON CULPRITS:
Muscle Tightness Quads, Hamstring, Gastroc Quad and Glut Weakness Single leg squat & step down Mal-Alignment Pes planus, patellar tilt, etc 

TREATMENTS FOR CULPRITS:
Stretches ( 3 sets of 1; 30 seconds each) Strengthening (PT, Biking) Orthotics (start with off the shelf)

Pearls o Finding a good physical therapist – A daunting but a necessary task. Common suggestions include asking an orthopedic surgeon or primary care sports medicine doctor for advice. Another option is to refer a healthy young patient with patellafemoral pain to a physical therapist. A therapist who focuses on strengthening and stretching exercises in conjunction with some patellar taping and bracing is worth referring to again. The therapist who focuses on modalities and minimizes the importance of exercise therapy is probably not going to be helpful to your patient over the long-haul.

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Treatment:

o What seems to work  Strengthening and Stretching Exercise (LOE A)  NSAIDs – limited evidence for small short-term pain relief (LOE A) o What might work  Orthotics or knee bracing (LOE B) o What doesn’t work  Aspirin (LOE B)  Ultrasound (LOE B) o References  Heintjes E, Pharmacotherapy for patellofemoral pain syndrome (Cochrane Review), Cochrane Library 2008 Issue 2.  D'hondt NE, Orthotic devices for treating patellofemoral pain syndrome (Cochrane Review), Cochrane Library 2008 Issue 2.  Heintjes E, Exercise therapy for patellofemoral pain syndrome (Cochrane Review), Cochrane Library 2008 Issue 2.  Brosseau L Therapeutic ultrasound for treating patellofemoral pain syndrome (Cochrane Review), Cochrane Library 2008 Issue 2.

TROCHANTERIC BURSITIS
 Epidemiology o Second most common cause of hip pain, following osteoarthritis o Hope your patient has troch bursitis: it’s an easy diagnosis and treatment Pathoanatomy o Tightness in the ileotibial band and weakness in the tensor fascia latae cause compression of the bursa between the tensor fascia latae and the greater trochanter. o Gluteus medius weakness also causes bursal compression due pelvis sagging in single-leg stance (Trendelenburg sign – Fig 3 ) Diagnostic Clues o Pain ranges from nagging to incapacitating o Typically described as lateral hip pain radiating towards the knee o Painful to get up out of a chair o No history of trauma Differential Diagnosis o Osteoarthritis o Hip Fracture (Stress, Trauma, Insufficiency, Pathologic) o Sciatica o Sacroiliac pain o Many others!

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Fig - 3

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VICTIM:

 Trochanteric Bursa

TREATMENTS FOR VICTIM:

 RICE  NSAIDs  Injection – Most evidence support

INJURY CULPRITS:
Iliotibial Band (ITB) Tightness Muscular Weakness (ITB, Glut) Training Error 

REHABILITATION FOR CULPRITS:
ITB Stretching Lateral leg lifts, Single leg step downs Correct training regimen

Pearls o Press on the Troch Bursa before giving up hope – Hip pain can be very complicated. Before abandoning all hope and referring to a specialist, press on the Trochanteric Bursa. If that causes pain similar to the patient’s complaint, think about trochanteric bursitis o Inject first; Ask Questions Later - a steroid & lidocaine injection into the trochanteric bursa is often both diagnostic and therapeutic. Treatment:

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o Steroid Injection (LOE B) No studies compare NSAIDs to injection and other forms of treatment. However, retrospective study shows injection patients 2.7 fold more likely to be pain free o If the pain returns or if patient is young/athletic, find & treat “culprits”

o References  Ege Rasmussen KJ, Fano N. Trochanteric bursitis. Treatment by corticosteroid injection. Scand J Rheumatol 1985;14(4):417-20.  Schapira D, Nahir M, Scharf Y. Trochanteric bursitis: a common clinical problem. Archives of physical medicine and rehabilitation 1986;67(11):815-7.  Shbeeb MI, O'Duffy JD, Michet CJ, Jr., O'Fallon WM, Matteson EL. Evaluation of glucocorticosteroid injection for the treatment of trochanteric bursitis. The Journal of rheumatology 1996;23(12):2104-6.  Lievense A, Bierma-Zeinstra S, Schouten B, Bohnen A, Verhaar J, Koes B. Prognosis of trochanteric pain in primary care. Br J Gen Pract 2005;55(512):199204.

SUBACROMIAL SHOULDER PAIN (ROTATOR CUFF SYNDROME)
 Pathoanatomy o Rotator cuff depresses humeral head and seats it firmly into glenoid o Big muscles of the shoulder (Pec, Deltoid, Trapizius) pull head of humerus superiorly “impinging” the rotator cuff against the acromion o If big muscles win, rotator cuff is injured and “turns off” causing progressively worsening impingment Pathoanatomy - “Listening” to the Shoulder o No or minimal (overuse) trauma o Pain most severe with overhead and behind the back motion o Night pain o Pain radiates down into the deltoid DDx: o o o o o

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AC joint sprain or OA Radiating/referred pain from neck Labral tear Biceps tendonitis Complete rotator cuff tear

VICTIM:

 Rotator Cuff & Subacromial Bursa

TREATMENTS FOR VICTIM:

 NSAIDs – limited evidence  Iontophoresis/Ultrasound – no evidence  Steroid Injection – (LOE B – best evidence)

COMMON CULPRITS:
Rotator Cuff Weakness – SUICIDE!! Subacromial osteophyte or Acromial downsloping Overuse

TREATMENTS FOR CULPRITS:
Rotator Cuff Strengthening -- Must Strengthen Rotator Cuff or Pain Will NOT Improve!! Diagnose with outlet or “scapular Y” X-ray (Sagital MRI) – can still try conservative treatment, but refer early if patient fails Correct training regimen, “re-balance” shoulder muscles

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Treatment: o Prefer physical therapy referral for rotator cuff strengthening to allow exercise monitoring  Exercise technique important  Pain can commonly increase with rotator cuff rehab exercise  If pain inhibits or prohibits therapeutic exercise:  Consider subacromial steroid injection (LOE B) Return to Activity o Returning to shoulder exercise without intact rotator cuff function will result in recurrent or worsening shoulder pain o Consider alternative culprits and/or refer for surgical treatment for persistent pain over 4 months

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o References:  Johansson K, Oberg B, Adolfsson L, Foldevi M. A combination of systematic review and clinicians' beliefs in interventions for subacromial pain. Br J Gen Pract 2002;52(475):145-52. Buchbinder R, Green S, Youd JM. Corticosteroid injections for shoulder pain. Cochrane database of systematic reviews (Online) 2003(1):CD004016. Blair B, Rokito AS, Cuomo F, Jarolem K, Zuckerman JD. Efficacy of injections of corticosteroids for subacromial impingement syndrome. The Journal of bone and joint surgery 1996;78(11):1685-9.

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CODING MUSCULOSKELETAL VISITS
Like all medical coding, musculoskeletal coding can be confusing and complicated. The following is intended to be used as guide to correct coding, but is not a definitive resource. Providers should check with a coding professional to ensure that their coding practice is in compliance with established guidelines.

5 DO’S AND DON’T’S
DO capture the time required to teach exercises, instruct on use of crutches, fit braces, and coordinate care  Brace fitting and care coordination can be included in the patient education or complexity sections of your E&M code  Crutch training can be coded as CPT 97116 or included in your E&M code  Exercise teaching can be included in your E&M code or billed as CPT 97110 DON’T forget to code injections – CPT 20610 for most injections DO use a 29 modifier  If you diagnose subacromial shoulder pain and do a subacromial injection at the same visit, use a 29 modifier with your CPT code of 20610. This tells the insurance company that you both diagnosed the subacromial pain and did the injection at the same visit DON’T forget to bill for Durable Medical Goods  Ankle braces, crutches, etc are durable medical goods and should be billed accordingly DO pay attention to how much time it takes to properly care for common musculoskeletal problems  Identifying “victims” is easy, but finding and apprehending the “culprit” can take a bit of time. Make sure your coding reflects this

CPT: Easy as 1, 2, 3
The 3 most common CPT codes in musculoskeletal medicine are listed below. 20610 – Injection of major joints and bursae (finger joints are 20600) 97116 – Gait training/Crutch Training 97110 – Therapeutic Exercise Teaching (15 minutes)


				
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