41ST Annual Goldfarb Clinical Conference
Valley Forge Casino Resort
King of Prussia, PA
11-08-13
James A Marks, DPM, FACFAS, FAPWCA
Medical Director, The Wound & Skin Healing Center of
Washington Health System
Foot and Ankle Specialists / Washington Physicians Group
Employed by Washington Health System
& Washington Physicians Group
Speakers’ Bureau for Shire Regenerative
Medicine
Father of 4 ~ Luca’s Grandfather
“Well done is better than well said.”
~ Benjamin Franklin
James A. Marks DPM, FACFAS, FAPWCA
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Summarize the most common causes and
treatment of plantar heel pain syndrome
Provide a unique educational experience for
your public audience
Expand your current referral pathways
within your community
www.pennfoot.com
James A. Marks DPM, FACFAS, FAPWCA
James A Marks, DPM
Fellow, American College of Foot and Ankle Surgeons
Causes of Heel pain
How to self treat before calling a Podiatrist
Heel pain work-up
Discuss treatment
New treatments
Surgical options
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James A Marks, DPM, FACFAS, FAPWCA
James A Marks, DPM, FACFAS, FAPWCA
www.pennfoot.com
James A Marks, DPM, FACFAS, FAPWCA
 2 million Americans each year
 90% of heel pain patients respond in 6 wks to 6 mo
 Commonly shared risk factors: overly tight calf
muscle, poor shoe choices, weight gain, barefoot
walking, or hard work surface.
 3 times your body weight is transferred into your
heel area with each step
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James A Marks, DPM, FACFAS, FAPWCA
 Obesity or sudden weight gain
 Tight Achilles tendon
 Change in walking or running habits
 Poor cushioning in shoes
 Change in walking or running surface
 Job that requires prolonged time
standing/walking
 Excessive pronation of the foot
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Buchbinder, R. N Eng J Med. 2004; 350: 2159-66.
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James A Marks, DPM, FACFAS, FAPWCA
Kelton Research 1,082 surveyed
James A Marks, DPM, FACFAS, FAPWCA
Plantar fasciitis/iosis
Plantar fibromatosis
Stress fracture
Nerve entrapment
Trauma
Calcaneal apophysitis
Tarsal tunnel syndrome
Calcaneal bone cysts / tumors
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James A Marks, DPM, FACFAS, FAPWCA
Mechanical
Neurological
Rheumatological
Traumatic
Infectious
Metabolic
Neoplastic
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James A Marks, DPM, FACFAS, FAPWCA
Mechanical
 primarily plantar fasciosis
Neurological
 primarily nerve entrapment
Rheumatological
 primarily seronegative arthritides
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James A Marks, DPM, FACFAS, FAPWCA
Plantar fasciitis
Heel Spur Syndrome
Inferior calcaneal bursitis
Heel bruise “Policeman’s Heel”
Stress Fracture
Fat pad pathology
Chronic compartment syndrome
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James A Marks, DPM, FACFAS, FAPWCA
 Calcaneal spurs are an adaptive response
to vertical compression of the heel
rather than longitudinal traction of the
plantar fascia
 Spurs do not grow in the plantar fascia
 Degenerative changes due to stress
reaction / micro-fractures
Kumai and Benjamin, J Rheumatol, 2002
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James A Marks, DPM, FACFAS, FAPWCA
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*First described by
Woods, 1812
Pain on standing, especially after
periods of inactivity or sleep
Pain subsides, returns w activity
Pain related to footwear – can be
worse in flat shoes w no support
Radiating pain to the arch & toes
In later stages, pain may
persist/progress throughout the
day
Pain varies in character: dull
aching, “bruised” feeling. Burning
or tingling, numbness, or sharp
pain, may indicate local nerve
irritation
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James A. Marks DPM, FACFAS, FAPWCA
History
Physical
Imaging
Blood tests
For inflammatory arthritis
Nerve conduction studies
For nerve pathology
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James A Marks, DPM, FACFAS, FAPWCA
Location of pain?
Nature of pain?
Duration of pain?
When does the pain occur?
Age, physical make-up,
activities?
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James A Marks, DPM, FACFAS, FAPWCA
Location with what structures are in the area
Is the pain sharp or dull or burning?
Is the pain acute or chronic?
Does it occur after activity?
Related to a person’s weight or activity?
What relieves the pain?
What has the patient already tried?
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James A Marks, DPM, FACFAS, FAPWCA
Palpation
Range of motion
Functional testing
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James A Marks, DPM, FACFAS, FAPWCA
(1) plantar fasciitis
(2) entrapment of the
first branch of the
lateral plantar nerve
(3) heel pain syndrome
(4) fat pad disorders
James A. Marks DPM, FACFAS, FAPWCA
www.pennfoot.com
James A Marks, DPM, FACFAS, FAPWCA
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James A Marks, DPM, FACFAS, FAPWCA
Plain film X-rays
Generally the starting point
Bone scans
Increased bone turnover
Ultrasonography
Soft tissue problems
CT Scan
MRI
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Plain Films
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Tech Bone Scan
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James A Marks, DPM, FACFAS, FAPWCA
MRI: T1
MRI: T2 fat suppressed
sagittal image abnormal
signal in proximal plantar fascia and bone marrow edema
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James A Marks, DPM, FACFAS, FAPWCA
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James A. Marks DPM, FACFAS, FAPWCA
www.pennfoot.com
James A. Marks DPM, FACFAS, FAPWCA
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www.pennfoot.com
Avoid walking barefoot
Shoe modifications
Icing and rest
Stretching
Night or resting splint
Supplemental arch support
(OTC vs. custom orthotics)
Oral & Topical NSAIDS
Seek out Podiatrist if not
better in 4 weeks
 Throw out all “bad” shoes
 Too soft not always good
 Crocs good for certain feet
 Running shoe the best
 Avoid flat shoes
 Shoes to Avoid:
Flip flops!
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NSAIDs
Cortisone injection ???
Air-heel brace, heel cup, heel lifts
OTC Orthotics, etc.
 Patient education:
Elimination of barefoot walking
Activity alteration - RICE after activity
Stretching of plantar fascia & Achilles tendon
Proper shoe gear
Weight loss program & Lifestyle change
James A. Marks DPM, FACFAS, FAPWCA
Reappoint in 3 weeks
YOU ARE NOW 3-4 WEEKS PAIN LEVEL 5 OR 
Reassess exam and review testing results
 Patient education reinforcement
 Physical therapy
 Cortisone injection
NSAID adjustment (oral & topical)
Night splint
Proper shoe gear
Off-loading DME products
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James A. Marks DPM, FACFAS, FAPWCA
YOU ARE NOW 7-8 WEEKS PAIN LEVEL 5 OR :
Reassess exam and chief complaint
 Patient education reinforcement
Reassess effectiveness of PT
Cortisone injection ??
NSAID adjustment (oral & topical)
 Rx: Custom Molded Orthotics
Special testing: MRI, Bone scan, EMG/NCV
Reappoint in 6-8 weeks
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James A. Marks DPM, FACFAS, FAPWCA
YOU ARE NOW 3-6 MONTHS PAIN LEVEL 5 OR :
Reassess exam & chief complaint
Any additional testing needed?
 Patient education reinforcement
Cortisone injection ??
NSAID adjustment (oral & topical)
 Immobilization
 Surgical intervention Referral
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James A. Marks DPM, FACFAS, FAPWCA
Shockwave treatment
Platelet Rich Plasma Injection
Topaz (Coblation)
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James A Marks, DPM, FACFAS, FAPWCA
For more information…
Monday through Friday
8 am – 4:30 pm
Wilfred R. Cameron Wellness Center
208 Wellness Way, Bldg.1