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Casebook of Orthopedic Rehabilitation Case 9 A Lady with Intractable Heel Pain 骨科康复病案：一位顽固足跟痛的女士 注意以下为微软在线自动翻译，未校正。 History and Examination 病史与检查 You got a referral from the family physician of a 42-year-old secretary Helen, who suffers from intractable right-sided inferior heel pain, particularly with the first few steps that she takes in the morning. She had difficulty waiting for the bus to go to her workplace. She had got to the point now of walking on her toes to avoid the terrible heel pain. 你得到了一个42岁的秘书海伦的家庭医生的推荐, 他患有顽固的右下脚跟疼痛, 特别是她早上采取的最初几步。她有困难等公共汽车去她的工作场所。她已经到了点, 现在走在她的脚趾, 以避免可怕的脚跟疼痛。 Initially, the pain tended to decrease with level ground ambulation, but now it has increased throughout the day. The pain is worsened by walking barefoot on hard surfaces or by walking upstairs. She did not notice any numbness or weakness. Helen believed that her symptoms started after chasing after buses on several occasions when she was late getting up in the morning for work, coupled with a recent change in the type of shoe wear. 最初, 疼痛倾向于减少与水平地面移动, 但现在它已经增加了一天。在坚硬的表面上赤脚行走或上楼走路会使疼痛恶化。她没有注意到任何麻木或虚弱。海伦认为, 她的症状开始后, 多次追赶公共汽车后, 她在早上起床上班, 加上最近的鞋子磨损类型的变化。 On physical examination, you found that Helen was obese, and tender to palpation at the antero-medial aspect of the right heel. You also noticed some ankle dorsiflexion tightness arising from the Achilles tendon. Her pain was exacerbated by passive dorsiflexion of the toes. There was no clinical evidence of enthesopathy, the heels were neutral, and there were no pes cavus or pes planus. There was no clinical suspicion of tarsal tunnel syndrome. 在体格检查中, 你发现海伦肥胖, 并且在右脚跟的 antero 内侧进行触诊。你还注意到了一些脚踝屈曲的紧张, 由于跟腱。她的疼痛因脚趾的被动屈曲而加重。没有临床证据 enthesopathy, 脚跟是中性的, 没有 pes cavus 或 pes 苔藓。没有对跗骨隧道综合征的临床怀疑。 According to her referring doctor, Helen had received conventional treatment including all the modalities listed below for her right heel, but failed to show improvement. The therapy she had previously received included advice to decrease weight-bearing activities and running, shoe inserts and heel pads, and night splints made to hold the ankle in dorsiflexion and the toe in extension. Plantar fascia stretching was also previously being prescribed by a local physiotherapist, who also administered ultrasound treatment to the affected area. 据她的主治医生说, 海伦接受了常规治疗, 包括下面列出的所有方式, 她的右脚跟, 但没有显示改善。她以前接受的治疗包括减少负重活动和跑步、鞋类插入物和脚跟垫的建议, 以及在屈曲和脚趾上保持踝关节的夜间夹板。足底筋膜伸展术以前也由当地理疗师规定, 他还对受影响的地区进行超声治疗。 How would you proceed from here? 你怎么从这里着手？ Discussion 讨论 Pain that is worse on first arising in the morning or after a period of rest is highly suggestive of plantar fasciitis, as is typical local tenderness at the point of attachment of the plantar fascia at the medial tubercle of the calcaneus. Risk factors include weight gain, repetitive stress, and middle age. Our patient at hand in fact has most of the risk factors. The plantar fascia extends longitudinally along the plantar surface of the foot, deep to the fibrofatty subcutaneous tissue and covers the intrinsic musculature and neurovascular structures. Tensile forces are concentrated at this attachment site, particularly on the medial tubercle of the calcaneus. 在清晨或休息一段时间后出现的疼痛, 是足底筋膜炎的强烈暗示, 在跟骨内侧结节的足底筋膜附着点上是典型的局部压痛。危险因素包括体重增加、重复压力和中年。我们的病人实际上有大部分的危险因素。足底筋膜沿足底足部纵向延伸, 深至 fibrofatty 皮下组织, 覆盖内部肌肉和神经血管结构。拉伸力集中在这个附着部位, 特别是在跟骨内侧结节。 Pathologic studies carried out more recently on surgically removed specimens demonstrate microtears of the fascia, collagen necrosis, angiofibroblastic hyperplasia, and chondroid metaplasia (JAAOS, 2006). 最近对手术切除标本进行的病理学研究表明, microtears 筋膜、胶原坏死、angiofibroblastic 增生和软骨样化生 (JAAOS, 2006)。 These changes are consistent with a chronic degenerative/reparative process secondary to repetitive stress or sometimes repeated microtrauma. The latter is evidenced by the frequent occurrence of heel pain in runners. The condition is bilateral in one-third of cases; a spur is present in half of all cases, as opposed to 15% in the general population. For bilateral cases, seronegative arthritis also needs to be ruled out. One possible source of pain may be a branch of the lateral plantar nerve. Anatomically, the first branch of the lateral plantar nerve is a mixed motor-sensory nerve to the abductor digiti quinti minimi, which passes superior to the attachment of the plantar fascia. Authors like Baxter have drawn attention to a possible impingement syndrome that can occur in several areas along the course of this nerve (OCNA, 1989). 这些变化是一致的慢性退化/修复过程继发重复性压力或有时重复创。后者在赛跑者经常发生脚跟痛苦证明。1/3 例均为双侧状态;在所有的情况中, 都有一个鞭策, 而在一般人口中则是15%。对于双边病例, 阴性关节炎也需要排除在外。一种可能的疼痛来源可能是侧底神经的一个分支。解剖上, 侧脚底神经的第一个分支是混合运动感觉神经对外展小指 quinti 小指, 通过优于附着的足底筋膜。像巴克斯特这样的作者已经提请注意一个可能的撞击综合征, 可以发生在几个地区沿着这神经的过程 (OCNA, 1989)。 The spur, however, need not necessarily be the source of the pain, for it is well accepted that even though a spur may be seen coincidentally or even associated with the clinical condition, it need not by itself be the etiologic factor. 然而, 刺激不一定是痛苦的源头, 因为它被接受, 即使是巧合地被看见的刺激或甚而与临床情况相关, 它本身不需要是病因因素。 That said, there is a chance the spur might add to neurogenic pain with compression of the first branch of the lateral plantar nerve mentioned above (OCNA, 1989). 这说, 有机会的刺激可能增加神经源性疼痛与压迫的第一个分支的侧脚底神经 (OCNA, 1989)。 Most surgeons and physiatrists treat plantar fasciitis conservatively. Taping is mentioned in the podiatry literature, but has not been evaluated scientifically with regard to plantar fasciitis. Shoe modification, such as use of a steel shank to limit MTPJ dorsiflexion during toe-off or a heel lift, and a change to wearing high-heeled shoes to decrease heel impact have also been tried with variable success. 大多数外科医生和 physiatrists 治疗足底筋膜炎保守。在足疗文献中提到了贴扎, 但对足底筋膜炎没有进行科学的评价。鞋修改, 如使用钢柄, 以限制 MTPJ 屈曲在脚趾关闭或脚跟升降机, 并改变穿高跟鞋, 以减少脚跟冲击也尝试了可变成功。 It is surprising that in a recent review article on the subject by Gill, the use of newer modalities like shockwave and magnetopulse therapy were not even mentioned. The author in fact found the use of shockwave therapy to be very useful in patients refractory to conventional physical therapy and shoewear modification. 令人惊讶的是, 在最近的一篇关于吉尔的评论文章中, 甚至没有提到使用诸如冲击波和 magnetopulse 疗法这样的新方法。作者实际上发现使用冲击波疗法是非常有用的患者的顽固性的常规理疗和 shoewear 修改。 Role of Shockwave Therapy 冲击波疗法的作用 The use of shockwave therapy for the management of heel pain was formally approved by the FDA in 2000 (Fig. 11). The mechanism of action is not known for certain, but possibly involves controlled internal fascial disruption that may initiate a healing response. 应用冲击波疗法治疗脚跟疼痛是 FDA 于2000年正式批准的 (图 11)。作用机制是未知的, 但可能涉及控制内筋膜中断, 可能会引发愈合反应。 Low-energy shockwave treatment is preferred to high-energy treatments. 低能量冲击波治疗是首选高能治疗。 High-energy shockwave treatments may produce side-effects in the form of periosteal detachments and even small fractures on the inner surface of the cortex. 高能冲击波治疗可能产生的副作用, 在骨膜支队的形式, 甚至小骨折的内部皮层的表面。 Fig. 11 Application of low-energy shockwave for plantar fasciitis 图11 低能量冲击波在足底筋膜炎中的应用 Pitfalls in Administering Shockwave Therapy 冲击波疗法管理中的误区
Learning Point 学习点
Fig. 12 Machine for the application of iontophoresis treatment 图12 用于离子导入处理的机器 References 引用 Rompe J-D (2002) Shock wave applications in musculoskeletal disorders. Thieme, Stuttgart Sems A, Dimeff R, et al. (2006) Extracorporeal shockwave therapy in the treatment of chronic tendinopathy. J Am Acad Orthop Surg, 14:195–204 Maier M, Steinborn M, et al. (2000) Extracorporeal shockwave application for chronic plantar fasciitis associated with heel spurs: Prediction of outcome by magnetic resonance imaging. J Rheumatol, 27(10):2455–62 Gudeman SD, Eisele SA, et al. (1997) Treatment of plantar fasciitis by iontophoresis of 0.4% dexamethasone: A randomized double-blind, placebo-controlled study. ASJM, 25(3):312–6 Carter R, Anderson, et al. (2003) Effects of iontophoresis current magnitude and duration on dexamethasone deposition and localized drug retention. Phys Ther, 83(2): 161–169 © Casebook of Orthopedic Rehabilitation Including Virtual Reality，Dr. David Ip |
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