Monday, February 22, 2010

Heel pain: Usual & unusual causes


Planter heel pain & posterior heel pain:
Plantar heel pain is a symptom commonly encountered by clinicians. A variety of soft tissue, osseous, and systemic disorders can cause heel pain. Tendonitis also may cause heel pain. Achilles tendonitis is associated with posterior heel pain. Bursae adjacent to the Achilles tendon insertion may become inflamed and cause pain.

HPT (heel pain triad): Labib et al described the heel pain triad (HPT). HPT is a combination of plantar fasciitis, posterior tibial tendon dysfunction and tarsal tunnel syndrome.

They hypothesized that failure of the static (plantar fascia) and dynamic (posterior tibial tendon) support of the longitudinal arch of the foot has resulted in traction injury to the posterior tibial nerve, i.e., tarsal tunnel syndrome.

When such a situation is present then all abnormalities i.e. plantar fasciitis, posterior tibial tendon dysfunction and tarsal tunnel syndrome must be recognized and treated.

Classification of planter heel pain: Planter heel pain can be sub-divided in to neural & non-neural pain. The non-neural pain can again be sub-divided into 2 bony & soft tissue pains.

Neural pain: Injury to the tibial nerve and its branches in the tarsal tunnel and in the foot is also a common cause. Entrapment of these nerves may play a role in both the early phases of plantar heel pain and recalcitrant cases (2). Patients with plantar heel pain accompanied by tingling, burning, or numbness may have tarsal tunnel syndrome (4).

Non-neural pain (bony pain): calcaneal fracture. Calcaneal stress fractures are more likely to occur in athletes who participate in sports that require running and jumping (4).

Non-neural pain (soft tissue pain): Several conditions such as plantar fasciitis, rupture of the plantar fascia and atrophy of the heel fat pad may lead to plantar heel pain (2). Heel pad atrophy may present with diffuse plantar heel pain, especially in patients who are older and obese (4).

Plantar fascia lesions: The most common cause of heel pain in adults is plantar fasciitis. Patients with plantar fasciitis report increased heel pain with their first steps in the morning or when they stand up after prolonged sitting (4). Lesions of the plantar fascia form an important group. Common lesions of the plantar fascia include plantar fasciitis, plantar fascia rupture, plantar fibromatosis, and plantar xanthoma etc. Many times the planter fascia pain may arise from foreign-body reactions, enthesopathy, and diabetic fascial disease (3).

Few common clinical diagnostic clues to 2 most common conditions

The dorsiflexion-eversion test is used to diagnose tarsal tunnel syndrome (TTS), whereas the windlass test (dorsiflexion and eversion of the ankle in combination with extension of the metatarsophalangeal) is used for plantar fasciitis. Both tests mechanically challenge various structures that have been associated with plantar heel pain. However the usefulness in differential diagnosis in planter heel pain remains a question (4,5).

Unusual cause of heel pain:

Less common causes of heel pain, which should be considered when symptoms are prolonged or unexplained, include osteomyelitis, bony abnormalities (such as calcaneal stress fracture), or tumor. Heel pain rarely is a presenting symptom in patients with systemic illnesses, but the latter may be a factor in persons with bilateral heel pain, pain in other joints, or known inflammatory arthritis conditions (4).

Deep-seated neurilemmomas in the foot can easily be overlooked and misdiagnosed as tarsal tunnel syndrome or plantar fasciitis because of the rarity, absence of palpable mass, and similarity of symptoms to those of other frequently encountered foot disorders. Marui et al reported neurilemmoma in the foot as a cause of heel pain. neurilemmoma that arose from plantar branches of the posterior tibial nerve and caused chronic heel pain. These cases are misdiagnosed as tarsal tunnel syndrome or plantar fasciitis. These cases are appropriately treated by surgery (6).


1. Labib SA et al; Foot Ankle Int. 2002 Mar;23(3):212-20.
2. Alshami AM et al; Man Ther. 2008 May;13(2):103-11. Epub 2007 Mar 30.
3. Jeswani T et al; Clin Radiol. 2009 Sep;64(9):931-9. Epub 2009 Jun 18.
4. Aldridge T; Am Fam Physician. 2004 Jul 15;70(2):332-8.
5. Alshami AM et al; Foot Ankle Int. 2007 Apr;28(4):499-505.
6. Marui T et al; Foot Ankle Int. 2004 Feb;25(2):107-11.

Sunday, February 7, 2010

The pelvic floor: part 3 (Guide line for care & physiotherapy)

Pelvic floor dysfunction is a disorder predominantly affecting females. It is common and undermines the quality of lives of at least one-third of adult women and is a growing component of women's health care needs (2). The reported prevalence rates of pain within the pelvis range from 3.8% to 24% in women aged 15 to 73 years (3). Pelvic floor dysfunction affects women of all ages and is associated with functional problems of the pelvic floor. Pelvic floor dysfunction describes a wide range of clinical problems that rarely occur in isolation (2).

Functional pelvic floor problems are perceived to have low priority compared with other health disorders, and treatment remains sub-optimal. Inherent in achieving and promoting better health care services for women is the need for better collaborative approaches to care(2,3).

There is a need to identify and develop comprehensive interdisciplinary, multi-professional strategies that improve the assessment and treatment of pelvic floor dysfunction in primary, secondary and tertiary settings(2).

The care guideline (1):

Whilst the primary clinical aim is to correct the anatomy, it must also be to preserve or restore pelvic floor function. As a consequence, these patients need careful clinical assessment, appropriate investigations, and counselling before embarking on a well-defined management pathway.

The latter includes behavioural and lifestyle changes, conservative treatments (pelvic support pessaries, physiotherapy and biofeedback), pharmacotherapy, minimally invasive surgery (intravaginal slingoplasty, sacrospinous fixation and mid-urethral tapes) and radical specialised surgery (open or laparoscopic sacrocolpopexy). It is not surprising that in this complex group of patients, a multi-disciplinary approach is not only essential, but also critical, if good clinical care and governance is to be ensured.

Physiotherapists in pelvic pain & pelvic floor management

* see the causes of CPC

Physiotherapists are uniquely qualified to manage these patients because of their knowledge of the musculoskeletal and nervous systems and their awareness of the relationships among pain, physiology, and function.

Physiotherapists approach to CPC (chronic pelvic pain) When evaluating women who have pelvic pain, practitioners must ask questions about history of urinary or fecal incontinence, dyspareunia, or pelvic pain with certain activities or associated with menses, surgery, or trauma.

* Common Diagnoses of Chronic Pelvic Pain (CPC)

• Pelvic Floor Tension Myalgia and Levator Ani Syndrome: Pain is produced in the back, vaginal, anorectal, lower abdominal, coccygeal, thigh & pubic regions.
• Dyspareunia: Pain occurs during vaginal penetration/intercourse in the vagina.
• Vaginismus: Vaginal muscles contract involuntarily when vaginal penetration is attempted, causing vaginal pain.
• Anismus: Pain is felt in the anorectal area. Constipation often results.
• Proctalgia Fugax: It produces rectal pain, often intense, of short duration or a strong dull ache of a longer duration. It can awaken you during sleep.
• Coccygodynia: It produces coccygeal (tailbone) and rectal pain.
• Chronic prostatitis: It produces urethral, bladder, testicular, penile, anal, & groin pain.
• Pudendal Neuralgia: It produces localized burning in perineal area, can be one sided.

Guide line of Physiotherapy for chronic pelvic pain & incontinence

Chronic pelvic pain can be due to an imbalance of musculoskeletal and neuromuscular functions. A source of pain can cause increased pelvic muscle spasm which creates more pain resulting in a vicious pain/spasm cycle. The pain felt from a normal touch can be intensified or abnormal i.e. burning, stinging and itching.

Physiotherapy treatment can help to relax the pelvic muscles and to release trigger points often found in these muscles, resulting in a decrease in pain. Desensitization of the tissues assists in returning the neuromuscular pain mechanisms to normal.

Tools for physical treatment in pelvic floor management:

1. Pain management techniques (included relaxation training)
2. Pelvic floor stimulation as a part of facilitation & strengthening
3. Strengthening of pelvic floor & abdominals (Excellent if EMG/US guided)
4. Posture & pelvic control
5. Biofeedback for pelvic floor including internal vaginal or rectal therapy techniques.
6. Teaching bladder &/or bowel management

Patient may need dietary management and dietary assessment also.

Pelvic floor exercises: Pelvic floor exercises are sometimes called Kegel exercises, after the obstetrician who developed them. Another name for the exercises is pelvic floor muscle training (PFMT). Pelvic floor exercises are one of the first-line treatments for stress urinary incontinence (SUI). Pelvic floor exercises make pelvic floor muscle stronger which tighten before pressure increases in abdomen, eg when you sneeze, cough or laugh. In 1998 Norwegian scientists carried out a six-month trial on different treatments for SUI with groups receiving pelvic floor exercises, electrical stimulation, vaginal cones or no treatment. The women who did pelvic floor exercises showed the most improvement.
Despite of training pelvic floor muscle if the muscles are not properly recruited during exercises then training may fail to show the benefits. Hence it is essential to
1. Identify the muscles.
2. Contract the muscles correctly.
3. Use fast and slow contractions
Pelvic floor exercises are best taught by a specialist physiotherapist.

1. Elneil S et al; Best Pract Res Clin Gastroenterol. 2009; 23(4):555-73.
2. Davis K et al; J Adv Nurs. 2003 Sep;43(6):555-68.
3. Prather H et al; Phys Med Rehabil Clin N Am. 2007 Aug;18(3):477-96, ix.

The Pelvic floor: Part 2 (problems, clue to guideline for treatment & the primary clinicians)

The pelvic floor is a highly complex structure made up of skeletal and striated muscles, support and suspensory ligaments, fascial coverings and an intricate neural network. Its dual role is to provide support for the pelvic viscera (bladder, bowel and uterus) and maintain functional integrity of these organs (4). So the pelvic floor represents the neuromuscular unit that provides support and functional control for the pelvic viscera. Its integrity, both anatomic and functional, is the key in some of the basic functions of life (1):

a. Storage of urine and feces
b. Evacuation of urine and feces
c. Support of pelvic organs, and
d. Sexual function

In pelvic floor dysfunction the aetiology is inevitably multi-factorial, and seldom as a consequence of a single aetiological factor (4). However, the problems that are encountered with pelvic floor can be broadly grouped into due to hypotonic or hypertonic status.

The hypotonic condition leads to: stress incontinence, fecal incontinence, and pelvic organ prolapse.
The hypertonic condition leads to: elimination problems, chronic pelvic pain, and bladder disorders that include bladder pain syndromes, retention, and incontinence. The hypertonic disorders are very common and are often not considered in the evaluation and management of patients with these problems (1).

A. The pelvic floor muscle (PFM) & respiration interaction:

Working on 40 female healthy nulliparous women, one study found a correlation between PFM contraction strength and forced expiratory flows. They found a positive correlation between PFM & forced expiratory flow i.e. better is the strength of PFM better is the forced expiratory flow. Basis on this correlation the researchers of this study recommended a coordinated abdominal and PFM training in diseases with expiratory flow limitations (2).

B. The PFM, abdominal muscle & intravaginal pressure:

Activation of the abdominal muscles might contribute to the generation of a strong pelvic floor muscle contraction, and consequently may contribute to the continence mechanism in women (3).

One study found defined patterns of abdominal muscle activity were found in response to voluntary PFM contractions in healthy continent women (3). Crucial findings from this study is discussed below:

1. During voluntary maximal PFM contractions: The transversus abdominus, internal oblique, and rectus abdominus muscles works with the PFM in the initial generation of maximal intravaginal pressure.
2. 2 phases of intravaginal pressure rise: PFM activity predominated in the initial rise in lower vaginal pressure, with later increases in pressure (up to 70% maximum pressure) being associated with the combined activation of the PFM, rectus abdominus, internal obliques, and transverses abdominus.

These abdominal muscles were the primary source of intravaginal pressure increases in the latter 30% of the task, whereas there was little increase in PFM activation from this point on.

This study suggests among the abdominal muscles EO (external oblique) muscle does not show any clear activation pattern along with PFM. The supposed work of this muscle thus is predominantly in postural setting prior to the initiation of intravaginal pressure increases.

C. Complexity of medical problems & consultation areas in pelvic floor dysfunction:

Complex problems of the pelvic floor: Pelvic floor problems affect either one or all the three compartments of the pelvic floor, often resulting in prolapse and functional disturbance of the bladder (urinary incontinence and voiding dysfunction), rectum (faecal incontinence), vagina and/or uterus (sexual dysfunction) (4).

In complete pelvic floor failure, all three compartments are inevitably damaged resulting in apical prolapse, with associated organ dysfunction. It is clear that in this state, the patient needs the clinical input of at least two of the three pelvic floor clinical specialities (4).

Who must attend these patients?

This compartmentalisation of the pelvic floor has resulted in the partitioning of patients into urology, colo-rectal surgery or gynaecology, respectively, depending on the patients presenting symptoms (4).

1. Butrick CW; Obstet Gynecol Clin North Am. 2009 Sep;36(3):699-705.
2. Talasz H et al; Int Urogynecol J Pelvic Floor Dysfunct. 2009 Dec 8.
3. Madill SJ et al; Neurourol Urodyn. 2006;25(7):722-30.
4. Elneil S et al; Best Pract Res Clin Gastroenterol. 2009; 23(4):555-73.

* Dear friends I have a musculoskeletal back ground. While reviewing these papers I hoped to review the musculoskeletal issues around the pelvic floor. This is not exactly what I wanted to review but I really wanted to present the full picture. Point A, B refers to arena of MSK physiotherapists.

Saturday, February 6, 2010

The pelvic floor: Part 1 (control of pelvic floor)

According to modern imaging techniques and surgical techniques the classical concepts concerning the subdivision of the pelvic connective tissue and muscles need to be revised (3). A compartmental clinical model basing on clinical requirements subdivides the pelvic cavity into anterior, posterior, and middle compartments which is feasible (3). Further the pelvic structures can be divided in three groups: the hollow organs, the endopelvic fascia and the muscles (1). Let us review how the pelvic floor is organised

A. The pelvic floor & it’s important parts: The pelvic floor is the support of the pelvic visceras. Important pats of pelvic floor are
1. The levator ani muscle
2. Perineum & it’s myofascial structures
3. Pelvic fascia & it’s reinforcements

The M. levator ani is the muscle of the pelvic diaphragm. Its parts were given different names depending on their function or localization (1). The levator ani muscle (LA) with its two bundles (pubo- and ilio-coccygeus) is the major component of this pelvic floor (2). LA is also called pubiocaudalis & ilio-coccygeus is functunally named as abductor caudae internus. In anatomic studies (based on cadaver studies) the pelvic floor is described as basin-shaped. But dynamic MRI reveals: at rest the levator ani probably has the shape of a dome and differ when contract (1).

Perineum is called urogenital diaphragm by many. Under the LA lies the perineum with it’s includes the musculofascial structures as follows (2):

Ventrally: urethral sphincter, ischio-cavernous and bulbospongious (in males)
Caudally: fatty tissue filling the ischioanal fossa.
As this area is mostly a fascial structure and contains only fair muscular components. Therefore, many authors do not accept the term "diaphragm" and the physiologic function is still a matter of discussion (1).

Pelvic fascia or the endopelvic fascia covers the muscles. The endopelvic fascia has to fix the organs in the pelvis and forms "streets" for vascular and nervous supply (1). It has following 4 major reinforcements:

1. the uterosacral and cardinal ligaments
2. the arcus tendineus fascia pelvis (ATFP) and
3. the arcus tendineus levator ani (ATLA)

B. Development and organization of the pelvic connective tissue in the human fetus (4,5)

In both fetal and adult preparations pelvic connective tissue can be subdivided into a presacral, a perirectal and a paravisceral compartment. Whereas the presacral and the perirectal compartment contain connective tissue, adipose tissue and supplying structures, the paravisceral compartment is mainly composed of adipose tissue. While only a very thin rectal fascia was found at the border of the perirectal compartment. Moreover it is shown that the ligaments of the pelvic cavity are only composed of the sacrouterine ligaments and the pubovesical ligaments in the female and the puboprostatic ligaments in the male (5). Lte us discuss the IU development of pelvic connective tissue in fetus.

Three periods are important for the differentiation of the pelvic connective tissue in fetuses (4).

a. During a first or mesenchymal period (9-12-week-old fetuses), all pelvic regions identical with the so-called pelvic spaces in the adult are filled with loose undifferentiated mesenchyme. Some pelvic organs are covered by a layer of condensed mesenchyme which later constitutes the connective tissue sheath of these organs.

b. During a second or fibrous period (13-20-week-old fetuses), dense connective tissue predominates. It is arranged in circular and semicircular systems covering the rectum, the bladder and the urethra as well as the peritoneal pouches. The arrangement of dense connective tissue is the same in the male and in the female fetus. No ligaments were found within the pelvic cavity apart from the pubovesical and the puboprostatic ligaments. The connective tissue sheaths of the pelvic organs differ from one another. At the level of the pelvic floor only some of them are directly connected with the parietal pelvic fascia. The pelvic spaces are filled by loose connective tissue.

c. During a third or adipose period (21-38-week-old fetuses) adipose tissue develops within the different compartments of the pelvic cavity so that the clear organization found during the second period is abolished.
C. Nerve supply of adult pelvic floor:

The innervation of the pelvic floor comes from the 2nd, 3rd, 4th anterior sacral roots; denervation affects pelvic dynamism (2). One study also demonstrates a clear segregation of the segmental motor neuron pools innervating the different pelvic floor muscles (6). Pudendal nerve stimulation elicited only polysynaptic reflex responses from S2 ventral roots.

D. Spinal control of pelvic floor muscles (6):
A prevalent notion in the literature is that the pelvic floor muscles behave as a unitary mass (6).
Various muscles of the pelvic floor region could be reflexly activated either individually or as a mass unit depending on the intensity of stimulation. Tactile or electrical stimulation of pudendal regions on either side of the body elicited responses of the sphincter ani externus. Neural apparatus of the striated musculature of the pelvic floor is capable of activating individually the different muscles that make up the system. Further the sphincter ani externus from one side, and muscles of the diaphragm pelvis from the other, are subserved by different neuronal circuits (6).

E. Configuration of static & dynamic pelvic floor (1,2):
Especially the anatomic form of the levator plate does not conform with physiologic concepts (1).
Configuration of static pelvic floor: The pelvis statics is supported by the combined action of all this anatomical structures anteriorly forming the perineal "hammock", medially the uterosacral and cardinal ligaments, posteriorly the rectovaginal fascia and the perineal body. The angles formed by the pelvic visceras with their evacuation ducts participate to the pelvic statics (2).
Configuration of dynamic pelvic floor: During the pelvic dynamics the modification of these angles expresses the action of the musculofascial structures (2).

F. Clinical anatomy i. Muscle injury in pelvic floor

LA is formed essentially by type I fibers (with high oxidative capability and presence of slow myosin) as in postural muscles. The aerobic metabolism makes LA susceptible to injury caused by excentric contraction and mitochondrial dysfunction (2).

ii. Nerve injuries in pelvic floor
Injury to one pudendal nerve did not alter the level of tonic activity of the sphincter ani externus. But bilateral injury of the pudendal nerve entirely abolishes both tonic activity and phasic responsiveness of the SAE without affecting the activity of the levator ani and abductor caudae internus muscles.

1. Schmeiser G et al; Radiologe. 2000 May;40(5):429-36.
2. Yiou R et al; Prog Urol. 2009 Dec;19(13):916-25. Epub 2009 Nov 6.

3. Fritsch H et al; Adv Anat Embryol Cell Biol. 2004;175:III-IX, 1-64.
4. Fritsch H; Ann Anat. 1993 Dec;175(6):531-9.

5. Fritsch H; Surg Radiol Anat. 1994;16(3):259-65.
6. Dubrovsky B et al; Exp Neurol. 1985 May;88(2):277-87.