Heel pain is commonly encountered in orthopaedic practice. Establishing an accurate diagnosis is critical, but it can be challenging due to the complex regional anatomy. Subacute and chronic plantar and medial heel pain are most frequently the result of repetitive microtrauma or compression of neurologic structures, such as plantar fasciitis, heel pad atrophy, Baxter nerve entrapment, calcaneal stress fracture, and tarsal tunnel syndrome. Most causes of inferior heel pain can be successfully managed nonsurgically. Surgical intervention is reserved for patients who do not respond to nonsurgical measures. Although corticosteroid injections have a role in the management of select diagnoses, they should be used with caution.

Plantar and Medial Heel Pain: Diagnosis and Management

Peripheral compression neuropathy is a common clinical entity but little human nerve material has been available for study. It has been difficult to develop an experimental model of chronic nerve compression which is reliable and reproducible, making it difficult to assess the various treatment modalities currently in use to manage this problem. In a recent study using a rat model, connective tissue and nerve fiber changes associated with chronic nerve compression were described by the authors. The present study expands this same model of chronic nerve compression to the multifascicular median nerve of the cynomolgus monkey, using this model to test whether or not current surgical treatment modalities for nerve entrapment will alter the course of chronic nerve compression. Using histologic and morphometric parameters, there did not appear to be a difference between nerves treated by decompression alone or by decompression and internal neurolysis. Total number of nerve fibers remained constant, as did axon size, but a demyelinating process was demonstrated which is a significant component of chronic nerve compression. Although the small number of experimental animals (7) makes precise evaluation of the clinical modalities impossible, the authors expect that further study of the multifascicular median nerve of the cynomolgus monkey will prove to be a useful source of future experimental evidence and will help to interpret the diverse therapeutic and operative techniques currently in use.

A primate model for chronic nerve compression

BACKGROUND The authors aimed to assess the effect of lower extremity nerve decompression surgery for painful diabetic polyneuropathy on pain and sensibility. METHODS The study was conducted as a single-center randomized controlled trial of one intervention with 1-year follow-up. Forty-two patients with painful diabetic neuropathy were included. After randomization, the lower extremity nerves were decompressed at four sites in one limb. The contralateral limb was used as control (within-patient comparison). All patients were assessed preoperatively and at 3, 6, and 12 months postoperatively. Primary outcome was the visual analogue scale score 12 months after surgery. Secondary outcomes were Semmes Weinstein monofilament testing and two-point discrimination outcomes at 3, 6, and 12 months. RESULTS Visual analogue scale scores improved significantly from a mean of 6.1 (95 percent CI, 5.5 to 6.7) preoperatively to 3.5 (95 percent CI, 2.5 to 4.4) at 12 months postoperatively (p<0.001). The score was also significantly lower compared with the control leg score of 5.3 (95 percent CI, 4.4 to 6.2; p<0.001) at 12 months. Overall, 73.7 percent of the patients improved their score on the visual analogue scale, of which 35.7 percent had a decrease of more than five points. CONCLUSION Surgical decompression of the nerves of the lower extremity can be added as a therapeutic option for patients with painful diabetic neuropathy who show signs of chronic nerve compression by means of a positive Tinel or other diagnostic criteria, when pain medication fails to reduce pain to an acceptable standard. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, I.

Value of surgical decompression of compressed nerves in the lower extremity in patients with painful diabetic neuropathy: a randomized controlled trial.

Background:
Despite proven benefits of upper extremity nerve decompression in diabetics, neurolysis for diabetic patients with lower extremity (LE) nerve compression remains controversial.

The Positive Effect of Neurolysis on Diabetic Patients with Compressed Nerves of the Lower Extremities: A Systematic Review and Meta-analysis.

Objective
To investigate the effect of surgical decompression on painful diabetic peripheral neuropathy (DPN) patients and discuss the role which pain distribution and characterization play in the management of painful DPN as well as the underlying mechanism involved.

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Surgical decompression of painful diabetic peripheral neuropathy: the role of pain distribution

Predictive ability of a positive Tinel sign over the tibial nerve in the tarsal was evaluated as a prognostic sign in determining sensory outcomes after distal tibial neurolysis in diabetics with chronic nerve compression at this location. Outcomes were evaluated with a visual analog score (VAS) for pain and measurements of the cutaneous pressure threshold/two-point discrimination. A multicenter prospective study enrolled 628 patients who had a positive Tinel sign. Of these patients, 465 (74%) had VAS >5. Each patient had a release of the tarsal tunnel and a neurolysis of the medial and lateral plantar and calcaneal tunnels. Subsequent, contralateral, identical surgery was done in 211 of the patients (152 of which had a VAS >5). Mean VAS score decreased from 8.5 to 2.0 (p <0.001) at 6 months, and remained at this level for 3.5 years. Sensibility improved from a loss of protective sensation to recovery of some two-point discrimination during this same time period. It is concluded that a positive Tinel sign over the tibial nerve at the tarsal tunnel in a diabetic patient with chronic nerve compression at this location predicts significant relief of pain and improvement in plantar sensibility.

/pdf/a-positive-tinel-sign-as-predictor-of-pain-relief-or-sensory-ubcgbg2110.pdf

A positive Tinel sign as predictor of pain relief or sensory recovery after decompression of chronic tibial nerve compression in patients with diabetic neuropathy.

Barret Sl

Papers

A positive Tinel sign as predictor of pain relief or sensory recovery after decompression of chronic tibial nerve compression in patients with diabetic neuropathy.