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Plantar Fasciitis

One of the areas, the plantar fascia, can be involved with plantar fasciitis as it inserts into the calcaneus and also the Achilles tendon as it inserts into the back of the calcaneus plantar fasciitis, planter fasciitis, fascitis, fasitis. These are very common problems. If there is any sense that it is chronic inflammatory in nature and there are other systems involved, really think of a spondyloarthropathy because these areas are very commonly involved with things like ankylosing spondylitis and the like plantar fasciitis. But I do see patients occasionally and thatís all they have. They just have Achilles tendonitis or plantar fasciitis. Sometimes you can even get bursal inflammation although itís very difficult to differentiate.

Plantar fasciitis, again the most common situation I see is someone who walks a lot. Mail carriers. They start out with a 50 pound bag of mail and itís hard on their feet. They just walk around and deliver mail all day. But anybody who is on their feet a lot, walking, carrying extra weight, and the pain is usually in the sort of medial aspect of the bottom of the calcaneus. Itís not dead center, because thatís not where the plantar fascia.

When you examine you can put a stress on the plantar fascia either by pushing on the forefoot up, or just putting your thumb right into this area of the insertion.

Treatment generally involves antiinflammatory drugs which often work quite well. Sometimes just modifying the shoes a little bit, getting some inserts. You can buy them in a drug store or sporting goods store. Sometimes a podiatrist can design an orthotics - or an orthopedic surgeon can design orthotics - that would help to relieve the strain of this plantar fascia. Corticosteroid injections can be useful. I donít like to do them repeatedly, again because this structure has a tremendous amount of stress on it. So Iíll do it once, maybe twice. A lot of times thatís all you need. Sometimes patients do need ongoing antiinflammatory treatment if they continue to do what it is that caused the situation.

Achilles tendonitis is going to be on the back of the heel and when you see this, you really should think of another cause, particularly spondyloarthropathies, fluoroquinolones antibiotics which are commonly used for urinary tract infections - at our hospital now the fluoroquinolones are first line for community acquired pneumonia. I guess they are just less expensive and easier to give, but itís not Cipro. I guess itís Levaquin, seems to work pretty well for upper respiratory-type infections and itís just easier than giving a combination of erythromycin and cephalosporin. But these antibiotics have been associated with Achilles tendonitis, among other tendonopathies, and it can occur very quickly and these patients can actually go on to rupture. So if you have a patient on a fluoroquinolone and they develop a tendonopathy, probably get them onto another antibiotic. Particularly Achilles tendonopathy.

Carpal Tunnel Syndrome. Carpal tunnel syndrome is the most common thing that we see. The symptoms are pain and burning in the wrist and hands. Often it is not that well localized. Patients donít read their neurology textbooks. They donít know where the median nerve goes versus the ulnar nerve. Often they complain that the entire hand is numb. The pain may radiate up to the arm, even up into the neck if it is very severe and very acute. Paresthesia and numbness are classic. Symptoms are very prominent at night, especially if the patients just happen to fold their wrists in a certain position. They may actually wake up with their hand asleep and have to shake it out in order to get the feeling back into it. Also, clumsiness. They donít have - even if they have normal sensation on exam - they donít feel the dexterity is there in their hand. Physical findings; the Tinelís sign. I find that thatís by far and away the best. You can do this with your finger, just like when you percuss or even with a reflex hammer over the carpal tunnel, which the best spot.

The hypothenar evidence marks the location of the carpal tunnel. If you tap there and the patient has pain, either radiating into their hands somewhere, their thenar evidence or their fingers, or up into their forearm, I consider that a positive sign. The Thalence is not quite as good. Thatís where you bend the wrist, either flex it or extend it for the reverse Thalence and then let it sit there for awhile. I donít find that is quite as useful. I donít feel like wasting a minute, having them sit there if the Tinelís sign is positive, thatís good enough for me. You may have abnormal sensory findings, occasionally weakness or even atrophy.

The other thing to remember is that carpal tunnel syndrome, like ulnar entrapment or tarsal tunnel syndrome, can be associated with certain underlying medical conditions. Diabetes is a big one. Hypothyroidism. I have picked up a few patients with hypothyroidism that were before undiagnosed. Occasionally gout, acromegaly because of changes at the specific sites, the wrist joint, pregnancy - obviously, that will resolve - synovitis at the wrist, particularly in RA, systemic sclerosis or scleroderma big time. These patients have severe problems and often donít even respond to surgery. Amyloidosis is another one that can be very resistant. Chronic renal failure on hemodialysis they can get amyloid deposits with Beta 2 microglobulin as opposed to other types of proteins. This can also be very resistant. Again, I mention repetitive strain injury, where they will have typical carpal tunnel syndrome on history.

The treatment includes, if they have an underlying condition like thyroid disease or diabetes, treat the hypothyroidism, that will often help. Rheumatoid arthritis, treating the synovitis with an injection in the wrist or maybe systemic treatment. That may help. Antiinflammatory drugs may help. Wrist splinting will help, particularly at nighttime.