What exactly is metatarsal fasciitis? How is it related to heel spurs? How can it be prevented, diagnosed and treated?
1. Misconceptions about heel spurs
The heel spur is medically known as “osteophyte”. In fact, heel bone hyperplasia is a phenomenon that results from the bone’s response to stress stimulation. The majority of patients do not have clinical manifestations of osteophytes in the heel, and they are only found incidentally during a physical examination or a medical visit. Only when the osteophytes develop to a certain extent, which can involve nerves and blood vessels, or when the osteophytes cause sterile inflammation of local tissues, will clinical symptoms arise. Therefore, the relationship between heel osteophytes and clinical symptoms is not a parallel one.
2.What is metatarsal fasciitis?
Metatarsal tendonitis mostly refers to the aseptic inflammation that occurs in the plantar tendon membrane at the beginning of the heel node and belongs to a kind of heel pain. It often occurs in people who have been standing or walking for a long time, and is a long-term, chronic lesion caused by the accumulation of minor trauma. The substance is a fracture of the fascial fibers and their repair process. There may be osteophytes in the inferior medial fascia of the heel bone and in the short flexor digitorum superficialis, forming a bony ridge. On lateral radiographs, this appears as a bone spur. The latter is often thought to be the cause of heel pain. However, clinical studies have shown that the causal relationship between it and heel pain is difficult to establish, and that metatarsal fasciitis is not always accompanied by bone spurs, nor do people with heel spurs necessarily have heel pain.
3. Anatomical basis and pathogenesis of plantar fasciitis
The plantar tendon membrane is a broad and thick bundle of soft tissue that starts at the heel node, extends forward along the plantar surface of the foot and attaches to the fat pad of the five toes, and ends at the periosteum of the toes, whose role is to maintain the relationship between the longitudinal arch of the foot and to participate in the activities of the plantar flexor tendons. Sometimes a tear located near the beginning of the heel bone or at the attachment of the flexor digitorum teres can cause inflammation and pain. Most of them are due to long-term standing work or long-term running, jumping and other sports, or flat feet, high arched feet, so that the plantar tendon membrane is under long-term tension, resulting in inflammatory exudation and edema at the appendage, thus causing pain.
4, the ancestral medical knowledge of this disease
Chinese medicine believes that the heel is the main stress-bearing part of the body. The liver is the main tendon and the kidney is the main bone. As the patient grows older, the function of liver and kidney decreases, and the loss of liver yin and kidney essence is not enough to moisten the tendons and bones, so the bones are weak and the tendons are loose. In addition, due to poor living habits, sports and other strains and injuries to the tendons and bones, the development of paralysis, blood stagnation, paralysis blocking the meridians and channels, do not pass, so see the heel pain. Qi injury pain, form injury swelling so see local swelling.
5.Diagnostic points
In the process of diagnosis and treatment of plantar fasciitis, the following points should be noted: ① Medical history: As plantar fasciitis occurs in middle-aged and elderly people with fat body shape and those who love sports. This is especially true for people who have recently undergone sudden exercise or changes in exercise patterns. Therefore, patients should be questioned in detail about their recent activities to discover the triggers or causes of the disease. ② Clinical symptoms: The pain of plantar fasciitis is characterized by heavier pain when getting out of bed in the morning or walking the first few steps after rest, and the pain can be partially relieved after further activities, but the symptoms can be aggravated again after prolonged activities. In severe cases, pain can be felt even when standing or resting. The main reason is that when resting, the feet are naturally relaxed and the plantar fascia is relaxed; while walking immediately after waking up, the plantar fascia will be stretched significantly causing pain; ③Signs The most obvious site of pressure pain in plantar fasciitis is located at the medial tuberosity of the heel bone and 2-3 cm from the beginning of the plantar tendon membrane, and the pressure pain is limited, unlike the pressure pain in subheel fat pad inflammation and bursitis. On examination, swelling of the anterior medial aspect of the heel is seen. In addition, the presence of abnormal foot force lines, tibial inversion, inversion of the foot and flat foot, high arch foot, and contracture of the Achilles tendon should be observed. The pain and pressure pain are more obvious when the ankle joint and toes are passively dorsiflexed; ④ Auxiliary examination: about 50% of patients can see bone spurs on the metatarsal side of the heel node. For patients with diagnostic difficulties, ultrasound and MRI can also be performed, and thickening of the metatarsal tendon membrane and edema can be seen.
6.Treatment
Although surgical treatment such as metatarsal fascia release or severance can be considered for patients whose symptoms do not resolve after non-surgical treatment, other problems may arise after surgery, so surgical treatment should be used with caution. It is essential to find safe and effective non-surgical treatments. Commonly used non-surgical treatments for this disease include, in addition to conventional rest and physical therapy, the following
1）Manipulation therapy
Manual therapy generally uses the top twisting method, using the thumb to apply top pressure at the site of pressure pain while doing twisting. However, large doses of stimulation are generally avoided in the acute stage.
2）Medication
Western medicine treatment can use non-steroidal anti-inflammatory drugs. Chinese medicine treatment includes internal medicine such as tonics, pills, powder, liquor, etc. Chinese medicine can be used to tonify the kidney and strengthen the bones, activate blood circulation and remove blood stasis, reduce swelling and pain. External treatment includes ointment, alcoholic external application, fumigation, external application, etc. External fumigation is mainly to tonify the kidneys and warm the yang, invigorate the blood and open the ligaments, together with water-relieving and decongesting drugs to obtain the effect, and fumigate the local area daily.
3）Small needle knife relaxation
The patient is placed in a prone position with the heel facing upward in a comfortable position. Local anesthesia is first applied to the most painful area, and then the needle is inserted vertically, with the incision line perpendicular to the longitudinal axis of the foot, and treated by lifting and inserting, puncturing and loosening method, longitudinal loosening method and spade loosening method. After covering the needle hole well, the plantar fascia can be passively retracted several times. If multiple treatments are needed, the treatment interval should be 1 week. After the operation, patients are advised to take proper rest, avoid strenuous exercise and overwork, and perform functional exercise for 1 to 2 months.
(4) Acupoint injection therapy
A mixture of trimethoprim 15mg or Depo-Provera 1ml and 2% lidocaine 2ml is injected locally in front of the heel tuberosity in a fan-shaped infiltration, usually 1-2 times. The time interval is 2-4 weeks depending on the type of hormone. Since closure brings about an increase in tendon fascia fragility, care should be taken not to overuse it.
5) Foot pads
The use of foot pads has a better therapeutic effect. If the heel pad is used to elevate the heel, it can reduce the tension of the metatarsal tendon and reduce the impact force on the heel, thus reducing the pain. For patients with combined flat feet, the longitudinal arch support part can be added at the same time to correct the poor force line of the foot, and semi-rigid adaptive foot pads are used for high arch feet.
6）Functional training
Plantar fascia pulling exercise method: patient sitting or lying down, ankle joint dorsal extension, using the hand to push the forefoot or toes to the dorsal side, maintain 30 seconds, repeated several times. Or place the front of the affected foot against the wall and dorsiflex the ankle joint with force, maintain for 30 seconds and repeat several times. The exercise should be performed every day right after waking up or before walking. In addition, other pulling exercises can be performed: Flounder muscle pulling exercise: the patient stands facing the wall with the affected side behind, slowly bend the knee joint to the flexed position, maintain for 30 seconds, and repeat 5 times. Gastrocnemius muscle pulling exercise: the patient stands facing the wall, the affected side is behind, keep the lower limb of the affected side straight, and the affected foot does not move, the heel cannot be lifted, the upper body moves forward, so that the Achilles tendon is pulled. Maintain 30 seconds, repeat 5 times. Achilles tendon pulling exercise, facing the support, body upright, body leaning forward, so that the Achilles tendon is pulled.