Plantar Fasciitis [plantar (on the sole of the foot) heel pain] and heel spur syndrome results from prolonged, excessive tension in the plantar fascia and leads to inflammation and fibrosis at the attachment of the plantar fascia to the calcaneus. Then, an elongated plantar spur may develop at the attachment of the fascia.

A patient with plantar fasciitis usually presents with pain in the heel on arising in the morning or after periods of rest (poststatic dyskinesia). The pain may subside after several steps, and then slowly worsen as the day progresses. In worse cases, the pain is persistent and may awaken the patient while sleeping. Some people describe a "stone bruise," sharp, sticking sensation, numbness or tingling in the sole of the foot.

Examination reveals two groups of patients with plantar fasciitis.

The first subgroup has plantar central palpatory tenderness at the insertion of the central band of the plantar fascia into the calcaneal (heel) tuberosity. Patients have little to no tenderness medial to this area. The calcaneal tuber is often prominent, and bursa are occasionally present.

The larger group of patients has increased palpatory tenderness along the plantar medial and inferior medial wall of the calcaneus. Pain may be elicited by active or passive extension of the foot and digits. Palpatory tenderness extends along the fascial band into the medial arch.

The heel spur or calcaneal spur is an osteophytic growth anterior to the medial calcaneal tuberosity that usually extends its entire width or about 2-2.5cm. DuVries described three types of calcaneal spurs:

1. Spurs that are large and asymptomatic because the angle of growth of the spur does not become a weight-bearing point or the inflammatory changes remain subacute.
2. Spurs that are large and painful with weight bearing because the pitch of the calcaneus has been altered by depression of the longitudinal arch. As a result, the spur becomes a weight-bearing point causing intractable pain through myositis of the intrinsic musculature and adventitious bursa formation.
3. Spurs that have a small amount of bony proliferation and whose outline is irregular and jagged, accompanied by an area of decreased density around the origin of the plantar fascia indicating a subacute inflammatory response.

Conservative treatment combines pharmacological, biomechanical, physical, and surgical therapies. Corticosteroids are the most potent group of medications. Any of the injectable preparations may appear to be appropriate, given through a medial or plantar approach.

NSAIDS (non-steroidal anti-inflammatory drugs) provide relief.

Physical therapy has a useful and sometimes limited role. Icing after periods of activity and stretching of the Achilles Tendon and plantar fascia appear helpful, especially when used after rest.

Night splints play a role by applying a constant passive stretch to tendons, fascia, and muscles by keeping the foot and ankle extended.

Short leg casting has proven effective. Successful orthotic therapy has been reported in podiatric literature.

O'Brien and Martin noted that orthotics were most helpful in patients with a history of heel pain lasting longer than 2.5 years. The use of heel cushions has been reported as a successful modality. Low dye strappings appear helpful.

Surgical procedures include neurolysis (excision of the lateral plantar nerve), heel spur resection, plantar fasciotomy (releasing the plantar fascia), and endoscopic plantar fasciotomy.

Morton Neuroma is the inflammation of a nerve due to the compression of surrounding bones. It most commonly occurs between the third and fourth toes at the ball of the feet. Possible causes include flat feet and wearing shoes that do not fit properly. More women will suffer from this type of neuroma from wearing pointed, high-heeled shoes that constrict the toes.

Patients will usually notice symptoms of Morton's neuroma during or after pressure has been placed on the balls of the feet by doing such activities as standing, walking, and running. Some of the most frequently described symptoms are:

• Localized pain between the toes (dull or sharp)
• Burning
• Loss of sensation
• Tingling
• Cramping
• Inflammation
• Sore to the touch

Your podiatrist must first rule out other conditions like rheumatoid arthritis and diabetic neuropathy, which have very similar symptoms. During your exam, your doctor may pull up on your first, second, and third toes while pushing down on your fourth and fifth toes. In most cases of Morton's neuroma, you will hear a click noise that is known as Morton's sign.

If he or she then determines that you are suffering from Morton's neuroma, a more conservative treatment is chosen first. The use of metatarsal pads, custom orthotics, and the use of proper fitting footwear can be expected for treatment.

The sooner you are diagnosed, the greater chance you have of successful conservative treatment.

If you are experiencing any of the symptoms addressed, we strongly recommend that you seek the advice of your podiatrist for proper diagnosis.

Osteoarthritis (Degenerative Joint Disease)

Osteoarthritis (OA) is a disease characterized by progressive loss of articular cartilage, appositional new bone formation in the subchondral trabeculae, and formation of new cartilage and new bone at the joint margins. The exact mechanisms by which primary osteoarthritis develops are unknown.

Secondary osteoarthritis is applied to the disease when it appears in response to some local or systemic pathology (disease process).

As far as pathology is concerned, the cartilage appears thicker than normal. An increase in water content leads to swelling of cartilage and an increase in the net rate of proteoglycan (any of a group of glycoproteins (class of protein) present in connective tissue and formed of subunits of disaccharides linked together and joined to a protein core. It serves as a binding or cementing material.) synthesis. The integrity of joint surface is lost and this leads to exposed bone.

Some symptoms include pain early after joint uses, particularly after prolonged activity of the joint and is relieved by rest. As the disease progresses, pain occurs at rest. One may have stiffness or muscle spasms.

One may experience tenderness on one side of the body and pain on joint range of motion. There may be joint enlargement due to bone proliferation, spurs, chronic synovitis (inflammation of synovial membrane) or effusion (escape of fluid into a part). One can have pain on passive range of motion and crepitus (crackling sound).

Xrays or radiographs appear normal in early stages, but may also show uneven joint space narrowing, marginal osteophytes (spurs), bone cysts and joint mice (loose osseous bodies).

Nonspecific synovial fluid reveals minimal abnormalities if any.

Primary OA's cause is unknown. In the hands one may see Heberden's nodes at the distal interphalangeal joints and Bouchard's nodes at the poriximal interphalangeal joints. In the feet one can have OA at the 1st metatarsophalangeal joint. OA is also seen in the knees, hips, and spine.

Secondary OA is caused by a local or systemic pathology. There may be trauma (post-traumatic joint malalignment). It may be due to metabolic or endocrine processes such as acromegaly(abnormal enlargement of the extremities of the skeleton). Another cause is Charcot joints.

Treatment includes patient education, rest, physical therapy (heat/ice, exercise, gait training), occupational therapy-splints, joint protection, assistive devices). Analgesics like asprin and acetaminophen may be used. Anti-inflammatory agents (NSAIDS, intra-articular corticosteroids) are helpful.

Surgical intervention may include correction of joint malalignment, debridement of loose bodies, spurs, osteotomy, arthrodesis (bone fusion) or partial or total joint replacement.