Effects of Gout – Uric Acid Crystals, Gout Attacks and Chronic Gout




Effects of Gout – Uric Acid Crystals, Gout Attacks and Chronic Gout
High Uric Acid Level
During a gout attack--your healthcare professional may refer to this as "acute gout"--excess uric acid begins to form crystals, causing inflammation in your joints that leads to the swelling and pain of a gout flare. These gout flares usually strike suddenly, at night, and without any warning. During the attack, the area becomes hot, red, swollen, and extremely tender. People describe gout in many painful ways--they say it's like a blow torch, a jackhammer, or walking barefoot on a bed of hot coals. And, unfortunately, once you have one gout attack, you're likely to have another.

For most people with gout--78% in fact--a second gout attack occurs within 6 months to 2 years of their first attack. Later attacks are more likely to involve more than one joint at a time. Attacks initially begin with less severity, eventually becoming more severe, lasting longer, with recovery taking longer than during initial gout attacks. And, gout attacks can become more common.

Talk to your healthcare professional if you're suffering from gout flares as he/she may prescribe medications or recommend over-the-counter treatments to address the pain and inflammation of your gout attacks. It's important to remember, though, that treating pain and inflammation doesn't address the underlying cause of gout, high uric acid. To help manage your gout over the long term, it is important to keep your uric acid level below 6 mg/dL. So, make an appointment with your doctor to discuss ways you may be able to achieve and maintain lower, healthy uric acid levels. To get the most from your appointment, use our Gout Conversation Card.

Common Foot and Ankle Problems - Dr. Vladimir Zeetser - Podiatric Physician and Surgeon




Common Foot and Ankle Problems - Dr. Vladimir Zeetser - Podiatric Physician and Surgeon
Common Foot and Ankle ProblemsFoot and ankle problems usually fall into thefollowing categories:
Acquired from improper footwear, physical stress, or small mechanical changes within thefoot.

Arthritic foot problems, which typically involve one or more joint.

Congenital foot problems, which occur at birth, are generally inherited.

Infectious foot problems, which are caused by bacterial, viral, or fungal disorders.

Neoplastic disorders, usually called tumors, which are the result of abnormal growth oftissue and may be benign or malignant.

Traumatic foot problems, which are associated with foot and ankle injuries.

Aesthetic - for additional information, please click here.

The most commonly treated foot problems are:
(alldescriptions are mainly in laymen's terms)
Bunion Deformity (Hallux Abductovalgus)Stiff Big Toe (Hallux Limitus/Rigidus)Tailor's Bunion or BunionettePlantarflexed or Dropped MetatarsalHammertoeHeel Pain, Plantar Fasciitis and Heel Spur SyndromeFlat Foot DeformityIngrown NailsNeuromasHallux Pinch CallusGoutGanglion CystAnkle SprainsSesamoiditisPlantar Wart or VerrucaTendonitis (Achilles Tendonitis)Pump Bump (Haglund's Deformity)Shin SplintsStress Fractures
Bunion Deformity (Hallux Abductovalgus)

A bunion deformity is a misaligned big toe joint thatcan become swollen and tender, causing the big toe to deviate towards thesecond toe and a bump or bunion to form on inside (medial aspect) of the bigtoe joint. As time progresses, the anglebetween the first and second metatarsal bones increases and the bunion becomeslarger. Initially, it may be withoutsymptoms, however because of the deviation at the joint, arthritis may developand destroy the joint and cause pain.Bunions are generally thought to be hereditary, but their developmentcan be exacerbated and hastened by tight fitting or narrow shoes, flat foot andhypermobility deformity. It becomes very difficult to wear shoes comfortablyand depending on the patient's age, can lead to skin breakdown and wounds. Conservative therapy is typically only temporaryand thus surgery is frequently performed to correct the problem.

Stiff Big Toe (Hallux Limitus/Rigidus)

This is a condition that affects the same joint as abunion, however on the top rather than the side. This is the result of arthritic anddegenerative changes occurring at the joint from wear and tear. Typically,spurs or bony growths form on the top of the joint causing pain and restrictingmotion. Often, the joint becomespermanently ruined and cannot be salvaged.Initially, steroid injections or orthotics may relieve the pain, howeverin the long term, surgery is usually indicated and there are a variety ofoptions available depending on the individual situation. This can include simply shaving off anyexcess bone, shortening the metatarsal to decompress the joint, fusing thejoint, and replacing the joint with an implant.More recently, synthetic joint fluid has been used to lubricate thejoint with some success and this can buy time before surgery is performed.

Tailor's Bunion or Bunionette

This is the equivalent to a bunion but is present on the outside of the foot at the fifth metatarsal bone.Causes and treatments are generally the same as for a bunion deformity.

Plantarflexed or Dropped Metatarsal

Clinically, this can present as an isolated painful callus or bone pain at the ball of the foot usually under the second metatarsal.Although any of the lesser metatarsals can be affected, typically the second metatarsal is too long or angled downward more than the others.Conversely, the first metatarsal may be too short or angled upward.In either case, the pain (called Metatarsalgia) is usually beneath the second metatarsal and difficult to resolve conservatively.Custom orthotics can control the symptoms, but for more long term relief, a surgical procedure can be performed to reposition the bone into a more normal position, usually shortening and/or elevating the bone as well.

Hammertoe

One of the most common conditions affecting the foot and usually stemming from muscle imbalance, in which the toe is bent into a contracted claw-like position. It occurs most frequently with the second toe, often when a bunion abuts and underlaps the toe, but any of the other three smaller toes can be affected.It can lead to painful corns, rubbing of the skin in shoes, wounds and general shoe fitting problems.Depending on the severity of the condition, conservative treatment is often ineffective and thus surgical correction is often necessary.This can include simply releasing a tendon in the toe, but often requires excising a small portion of bone.

Heel Pain, Plantar Fasciitis and Heel Spur Syndrome

This general category results in pain to the inside (medial aspect) of the heel which can occur suddenly or have a gradual onset.It occurs from excessive tension on the plantar fascia, the tendon attaching on the bottom of the heel bone, which results in microtearing and inflammation.With time and continued stress, the muscle pulls at its attachment to the heel bone and eventually produces a calcified spur visible on x-ray.

Typically described by patients as a very painful sensation upon arising in the morning and trying to make the first step of the day.After anywhere between 10-30 minutes, the pain subsides and the day progresses with a dull aching constant pain.Upon relaxing and being seated the pain tends to go away and then when the patient arises again to start walking the cycle starts all over again with very painful first step. Conservative treatment typically consists of injections, anti-inflammatory medications, stretching exercises, orthotics and sometimes physical therapy.For the 5-10% of patients that do not completely improve with conservative care, additional options remain.Prior to considering open surgery, a successful treatment called Extracorporeal Shock Wave Therapy (ESWT), first introduced as Ossatron, has been used for decades safely to procedure up to 92% success rates with one treatment.

Flat Foot Deformity

This condition can be congenital or acquired and typically results in hyperpronation of the subtalar joint in the foot.A variety of other causes occur as well.Gradually, the medial arch collapses and the foot becomes progressively flatter.As the deformity continues, the shape of the foot is drastically altered and the bones, joints and soft tissue structures deteriorate.If caught early in life, this can be corrected with relatively simple surgical procedures such as a subtalar joint implant.Later in life, this becomes more difficult and more extensive surgery may be required.Conservative care typically consists of high quality custom foot orthotics.

Video of CSI in the News
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Ingrown Nails

Toenails whose corners or sides dig painfully into the skin. Ingrown toenails are frequently caused by improper nail trimming, but also by shoe pressure, injury, fungus infection, heredity and poor foot structure. Women are much more likely to have ingrown toenails than men.Sometimes ingrown nails can be prevented by trimming toenails straight across, selecting proper shoe style and size and seeking care early.If the ingrown toenail becomes painful and/or infected, treatment consists of removing the offending nail border under local anesthesia to relieve pressure and pain.If the condition repeatedly occurs, a permanent correction can be performed either chemically or surgically, depending on the specific situation.

Neuromas

Enlarged benign growths of nerves, most commonly between the third and fourth toes. They are caused by tissue rubbing against and irritating the nerves. The symptoms include burning, numbness or cramping between the toes or in the ball of the foot.Pressure from ill-fitting shoes or abnormal bone structure can also lead to this condition. Treatments include orthoses (shoe inserts) and/or cortisone or alcohol injections, but surgical decompression or removal of the nerve is sometimes necessary.New techniques such as cryoablation (freezing the nerve) or radiofrequency ablation have shown promise as well.

Hallux Pinch Callus

This is a painful callus seen along the side of the great toe.A simple procedure removes the bony prominence which is the underlying cause of the hard callus formation.

Gout

This usually presents as a red, hot, swollen joint (most commonly the big toe joint).The pain is usually severe and causes limping.This is a metabolic disorder associated with elevated uric acid levels in the blood, mainly from dietary sources.If untreated, long term damage to the joint can occur, occasionally requiring surgery.In most cases, the condition can be managed with medication alone.However, during intermittent flare-ups, cortisone injections can be administered to relieve symptoms.

Ganglion Cyst

This is usually a benign soft tissue mass filled with a thick jelly like fluid.They often arise from a joint capsule or tendon sheath.A lump beneath the skin can cause pressure on a nearly nerve or pain in shoes.These fluid-filled masses are fairly common and can be present in many locations on the foot, but usually on the top.Without symptoms, they can be left alone; however, if they continue to enlarge and cause pain, the fluid can be drained.If the mass continues to fill with fliuid, it may require surgical removal.

Ankle Sprains

An ankle sprain is an injury to one or more ligaments to the ankle joint, usually on the outside (lateral aspect).These typically occur from twisting motions of the joint during a fall or from direct trauma.Early aggressive treatment typically yields the best results and fastest recovery.Ignoring the problem can lead to chronic ankle pain and a permanently weak and unstable ankle.Surgery is rarely indicated unless other associated injuries are sustained.

Sesamoiditis

This presents as pain directly beneath the 1st metatarsal (big toe joint) caused by inflammation or damage to any of the two small bones (sesamoids).Treatment includes offloading in a special shoe, orthotics, cortisone injections and occasionally surgical removal of bone fragments.

Plantar Wart or Verruca

Caused by strains of Human Papilloma Virus (HPV), this is probably the most difficult to resolve dermatological condition on the feet.Due to the high recurrence rate, a multitude of treatment options are available, but most are ineffective for warts on the bottom surface of the foot.Dr. Zeetser typically utilizes an injectable anti-cancer medicine with the highest clinical success rate.

Tendonitis (Achilles Tendonitis)

Inflammation of a tendon or the tissue surrounding it is called tendonitis.Pain is typically felt with motion of the tendon or weightbearing.Any tendon in the foot may be involved, however the Achilles tendon is most commonly affected.Conservative treatment includes anti-inflammatories, physical therapy, orthotics, and topical analgesics.Dr. Zeetser utilizes an injectable non-steroidal anti-inflammatory medication, without the risks of cortisone, to provide effective relief of symptoms.In severe or chronic cases, surgery may be indicated, and new techniques such as ESWT or the TOPAZ procedure can be employed.
Click here for additional information on newer techniques.

Pump Bump (Haglund's Deformity)

This is typically seen on the back of the heel as an enlarged swelling underneath the Achilles tendon.Usually caused by an enlarged bone mass with overlying tissue swelling on the back of the heel, which may take years to develop.The bump typically becomes enlarged and painful from rubbing on the back of shoes or "pumps."Conservative treatment consists of heel lifts, shoe padding, orthotics and occasionally injections.If this fails, surgery may be necessary to remove the bone and tissue mass.

Shin Splints

Pain to either side of the leg (tibia) bone, caused by muscle or tendon inflammation.It is commonly related to excessive foot pronation (collapsing arch), but may be related to a muscle imbalance between opposing muscle groups in the leg.Proper stretching, physical therapy and corrective orthotics can help prevent or alleviate shin splints.

Stress Fractures

This presents as a gradual onset of pain (usually in the midfoot) caused by overuse.Stress fractures are small incomplete cracks in bone and with early diagnosis and treatment, the condition typically heals completely. Untreated, they may become complete fractures, requiring casting, immobilization and occasionally surgery and may result in long term complications.



Tinea (Ringworm, Jock Itch, Athlete's Foot)




Tinea (Ringworm, Jock Itch, Athlete's Foot)

If your kids are active, locker-room showers and heaps of sweaty clothes probably are part of their everyday lives -- and so is the risk of getting fungal skin infections.

Jock itch, athlete's foot, and ringworm are all types of fungal skin infections known collectively as tinea. They're caused by fungi called dermatophytes that live on skin, hair, and nails and thrive in warm, moist areas.

Symptoms of these infections can vary depending on where they appear on the body. The source of the fungus might be soil, an animal (most often a cat, dog, or rodent), or in most cases, another person. Minor trauma to the skin (such as scratches) and poor skin hygiene increase the potential for infection.

It's important to teach kids to take precautions to prevent fungal skin infections, which can be itchy and uncomfortable. If they do get one, most can be treated with over-the-counter medication, though some might require treatment by a doctor.
Ringworm
Ringworm isn't a worm, but a fungal infection of the scalp or skin that got its name from the ring or series of rings that it can produce.

Symptoms of Ringworm
Ringworm of the scalp may start as a small sore that resembles a pimple before becoming patchy, flaky, or scaly. These flakes may be confused with dandruff. It can cause some hair to fall out or break into stubbles. It can also cause the scalp to become swollen, tender, and red.

Sometimes, there may be a swollen, inflamed mass known as a kerion, which oozes fluid. These symptoms can be confused with impetigo or cellulitis. The distinctive features of ringworm are itching, redness on the skin, and a circular patchy lesion that spreads along its borders and clears at the center.

Ringworm of the nails may affect one or more nails on the hands or feet. The nails may become thick, white or yellowish, and brittle.

If you suspect that your child has ringworm, call your doctor.

Treating Ringworm
Ringworm is fairly easy to diagnose and treat. Most of the time, the doctor can diagnose it by looking at it or by scraping off a small sample of the flaky infected skin to test for the fungus. The doctor may recommend an antifungal ointment for ringworm of the skin or an oral medication for ringworm of the scalp and nails.

Preventing Ringworm
A child usually gets ringworm from another infected person, so it's important to encourage kids to avoid sharing combs, brushes, pillows, and hats with others.



Neurologic Approach to Diagnosis of Low Back Pain




Neurologic Approach to Diagnosis of Low Back Pain

NEUROLOGY IN PRACTICE



Neurologic Approach to Diagnosis of Low Back Pain
James R. Lehrich, MD
Harvard Medical School


Key words: back pain, pain, lumbar spine, lumbardisks
Introduction
Low back pain is extremely common and has major economic significancein industrial societies. It is reported to occur in 26% of the working populationeach year and occurs to a disabling degree in 2 to 8%. Eighty percent ofthe population have at least one episode of low back pain in their lifetimes.It is the fifth leading reason for medical office visits in the United States.Low-back injury compensation accounts for 33% of all workers' compensationcosts (1/3 for medical treatment, 2/3 for indemnity). Seventy-five percentof compensation payments go to back patients, although they constitute only3% of total compensation patients (Klein et al, 1984; Hart et al, 1995).

Low back pain occurs most frequently between the ages of twenty and fortyand is more severe in older patients. There is no strong association basedon sex, height, body weight, or physical fitness. High-risk occupationsinclude miscellaneous labor, garbage collection, warehouse work, and nursing,all of which are usually associated with lifting, twisting, bending, andreaching.

Prognosis

The typical attack involves 35 days (median) of pain and 9 to 21 daysout of work. Those who are out of work longer than 6 months have only a50% likelihood of returning. This drops to 25% after more than 1 year outand to nil after 2 years. After an initial episode, the probability of recurrenceis increased fourfold. Treatment tends to be less successful in workers'compensation cases. The average cost for care is 4.5 times greater if thepatient is represented by an attorney.

Classification
Low back pain is an important part of neurologic and general medicalpractice. Of all office visits for back pain, 56% are to family practitionersand internists, 25% are to orthopedic surgeons, 7% are to neurosurgeons,and 4% are to neurologists. These patients make up 10% of the average neurologist'scaseload (Hart et al, 1995). The neurologist is usually called upon to evaluateand treat the patient with acute or subacute pain and symptoms and signsof nerve-root irritation-radiating pain, weakness, numbness, and bladderor bowel symptoms. Such patients make up a small minority of those withlow back pain. In many of these cases, the neurologist is also asked toassess the presence and degree of impairment (physical defect) and disability(what the patient can or can't do as a result of this defect) (AMA, 1993).

There are a multitude of causes of low back pain. Even when there isevidence of nerve-root involvement (radiculopathy), not every patient hasa herniated lumbar disc. The classifications outlined inTable 1 may be helpful in the differential diagnosis.

Clinical Evaluation
As for any neurologic patient, the general physical and neurologic examinationsand history are essential. This discussion will emphasize areas of specialconcern in the evaluation of back pain.

History

Particular note should be made of any preceding trauma, prior attacksof pain, prior evaluations, prior or current treatment, and the durationand progression of symptoms. The patient should be asked about weakness;numbness; dysesthesias and paresthesias; bladder, bowel, and sexual dysfunction;and any accompanying abdominal or flank pain.

Pain

Inquire as to the quality, location, and radiation of pain, and any exacerbatingor relieving factors and activities. Severe, constant back pain persistingat night suggests the presence of neoplasm, infection, or lateral recessnerve-root compression. Pain fibers are present in the annulus surroundingthe disc (in the spinal ligaments, facets, and joint capsules) but not inthe intervertebral disc itself. Nerve-root pain is usually brief, sharp,and shooting, is often increased by coughing, straining, standing, or sitting,and is usually relieved by lying down.

Peripheral-nerve or plexus pain is usually described as burning, tingling(pins and needles), or "asleep" or numb in quality; it is usuallyworse when the patient is lying down at night. (SeeTable 2.) In painful radiculopathies and mononeuropathies, the areaof pain and sensory abnormality may extend beyond the known sensory distributionof the affected peripheral nerve or beyond the dermatome of the affected-rootor dorsal-root ganglion, as in postherpetic neuralgia. This phenomenon hasbeen attributed to central nervous system plasticity. In most nerve-rootsyndromes, however, a precise description of radiating pain will help localizeto a nerve-root level.

Physical Examination

The general physical examination can be as important as the neurologicexamination and should include the vasculature (especially the pedal pulses),abdomen, inguinal areas, and rectum (especially if a cauda equina syndromeis suspected). The patient should be undressed.

Watch how the patient moves, sits, and stands. Look for atrophy (measurethe calf and thigh circumferences for asymmetry), fasciculations, pelvictilt ("bad" side is down), involuntary knee flexion (to guardagainst root traction), scoliosis, and cafe au lait spots (they might indicateneurofibromatosis). Gait testing should include walking on heels and ontoes.

Palpate the lower spine, paraspinal muscles, sciatic notches, and sciaticnerve looking for tenderness, muscle spasms, and radiating pain. Muscletenderness may be associated with nerve-root irritation (calf muscles withS1, anterior tibial muscles with L5, and quadriceps with L4).

Nerve Root Stretching
Roots may be impinged upon or tethered by herniated discs or other lesions,so that stretching the root causes pain. This should be tested by havingthe patient bend forward or by straight-leg raising (SLR). SLR is performedby raising the extended leg of a supine patient to determine whether thisaction elicits pain in the leg, buttock, or back, and, if so, at what anglefrom the horizontal the pain occurs. The pain is usually worsened by dorsiflexionat the ankle and relieved by flexion of the knee and hip. Positive SLR resultsusually indicate S1 or L5 root irritation. Pain occuring in the contralateral,symptomatic leg when the asymptomatic leg is raised is considered a positivecrossed SLR test, which usually indicates the presence of a disc herniationmedial to the nerve root, often with an extruded disc fragment. ReverseSLR tests detect L3 or L4 root irritation. The patient lies prone or onhis side, and the thigh is extended at the hip joint. If the patient haship or groin pain, the examiner should rotate the hip; pain on hip rotationsuggests hip disease rather than radiculopathy.

Motor Examination
It is helpful to bear in mind certain features of the motor examinationof the lower extremities in patients with low back pain. Since it is difficultto detect proximal leg weakness when the patient is lying down, it may benecessary to ask her to attempt to rise from a squatting position. Similarly,gastrocnemius weakness is easiest to detect with repeated rising up on thetoes. Toe flexors and extensors usually become weak before the foot musclesdo. If the gluteus maximus (supplied by S1) is weak, one buttock may sag;gluteus medius (L5) weakness may cause a lurching or waddling (Trendelenburg)gait. In a patient with root pain, do not test the dorsiflexors of the footwith the knee extended, since this may stretch the S1 or L5 root and increasesciatic pain. For the same reason, quadriceps strength should be testedwith the patient prone. Muscles are innervated by more than one nerve root,so total paralysis implies a lesion of multiple roots or of peripheral nerves.Even if a single root has been severed, there is little weakness. Atrophyis rarely seen unless symptoms have been present for more than three weeks.Severe atrophy should raise the suspicion of an extradural neoplasm.

Sensory Examination
A dermatomal distribution of loss of pinprick and touch sensation indicatesand localizes root involvement







(Figure1).



Dermatomal and peripheral nerve sensory distributions (from Keegan,JJ, Garrett, FD. Anat. Rec. 102:411, 1948; and Haymaker, W, Woodhall,B. Peripheral Nerve Injuries. 2d ed. Philadelphia. Saunders. 1953).







Because there is a wide overlap of root distributions, a single rootlesion usually causes mild hypalgesia. The examiner may not be able todetect any sensory deficit, even though the patient has sensorysymptoms.

Tendon reflexes
Asymmetry of the ankle and knee jerks can be helpful in identifying theaffected nerve root.

Nerve-Root Syndromes

In S1 nerve-root syndromes (see Table 3),leg pain is often worse than low back pain. Pain and paresthesias are feltin the buttock, posterior thigh, posterolateral calf and heel, and sometimesin the lateral foot and last two toes. Numbness and pinprick hypalgesiamay be in the fifth toe and lateral foot, and, to a lesser degree, in theposterolateral calf and posterolateral thigh. There may be weakness of thetoe flexors, the gastrocnemius, and (rarely) the hamstrings as well as toeadbuction and eversion of the foot. The ankle jerk is often diminished orabsent.

In L5 nerve-root syndrome, low back pain is often worse than leg pain.Pain and paresthesias radiate to the posterolateral thigh, groin, lateralcalf, dorsomedial foot, and first two toes. Numbness and hypalgesia maybe found in the great toe and medial foot, and, to a lesser extent, theanterolateral calf. Weakness may be noted in the extensor hallucis longus(EHL), the tibialis anterior (TA), and peroneal muscles, causing a footdrop. There is usually no reflex loss.

In L4 and L3 nerve-root syndromes, low back pain is worse than leg pain.There may be some anterior thigh pain. Numbness and hypalgesia may be presentover the anteromedial thigh and knee. Weakness may be detected in the quadricepsand iliopsoas muscles. The knee jerk is often diminished or absent.

Inconsistencies

Since some patients with back pain may exaggerate their symptoms, especiallyin medicolegal or workers' compensation cases, it is important to detectinconsistencies in the clinical presentation (Macnab and McCullock, 1990;Waddell et al, 1980). The history may indicate that the patient is ableto engage in activities inconsistent with the severity of his complaints.Symptoms may be described in an exaggerated or histrionic manner. Duringthe examination, tenderness may be elicited by minimal pressure or overareas where pain would not be expected. Axial loading, by pressing downon top of the head, or rotating the body at the hips or shoulders shouldnot elicit low back pain. It may be helpful to distract the patient, tosee whether there is more mobility in spontaneous activities than elicitedduring the formal examination. The patient may be observed during dressing(especially shoes and socks) and getting on and off the examination table.Straight-leg raising (SLR) should be tested when she is in a sitting position(e.g., while testing the plantar responses or measuring the calf circumferences)as well as when supine. There should be no significant difference in thedegree of hip flexion with sitting or supine SLR or when the patient bendsforward while standing. Nondermatomal or otherwise nonanatomic distributionsof sensory loss should also be noted. In the motor examination, sudden givingway, jerky movements, or weakness appearing to involve many muscle groupsshould raise suspicion. Note whether the patient appears to overreact duringthe examination, including what appears to be a disproportionate verbalizationof pain on minimal provocation, dramatic facial expressions, muscle tensionand tremors, collapsing when asked to bear weight, and requiring a companionfor dressing and undressing. These observations must be considered in thecontext of the overall examination. Severe pain can cause extreme reactionsin some patients.

Laboratory Evaluation
Laboratory tests are not necessary in every patient. They are importantto verify the diagnosis if surgery is contemplated and are sometimes necessaryto clarify the differential diagnosis. Since X rays, CT and MRI scans, myelograms,and other tests may be abnormal in asymptomatic patients, the results mustbe interpreted with the entire clinical presentation in mind. Some guidelinesare outlined in Table 4. (For a detailed discussion,see "Laboratory Evaluation of Low Back Pain" in this issue.)

Management
Most patients with back pain will respond to conservative treatment.Guidelines appropriate to the primary care physician as well as to the neurologistare outlined in Table5 . (For a more detaileddiscussion, see "Management of Low Back Pain" in this issue.)

References
Klein BP, Jensen RC, Sanderson LM: Assessment of workers'compensationclaims for back strains/sprains. J Occup Med 26:443, 1984.

Hart LG, Deyo RA, Cherkin DC: Physician office visits for low back pain.Frequency, clinical evaluation, and treatment patterns from a US NationalSurvey. Spine 20:11, 1995.

American Medical Association. Guides to the evaluation of permanent impairment,4th ed. Chicago: AMA, 1993.

Macnab I, McCullock J: Backache, 2nd ed. Baltimore: Williams and Wilkins,1990.

Waddell G, McCulloch JA, Kumel EG, et al: Nonorganic signs in low backpain. Spine 5:117, 1980.

Miller GM, Forbes GS, Onofrio BM. Magnetic resonance imaging of the spine.Mayo Clin Proc 64:986, 1989.


Copyright (C) 1996 Massachusetts Institute of Technology








Heel Spur Symptoms


It is rare for surgery to be required in the treatment of plantar fasciitis More than 90% of patients fully recovery from symptoms of plantar fasciitis within 12 months of the beginning of treatment using non-invasive treatment methods. Only in the worst cases is surgery needed. Surgery should only be considered where everything else has failed. Only patients who have completed a well-structured non-invasive course of treatment for over 9 months should consider plantar fasciitis surgery. What Is More, before agreeing to a plantar fasciitis surgery, you must fully comprehend both the potential dangers and gains of surgery.

Heel pain is usually felt in two main sections of the heel, under the heel and in the back of the heel. In most cases, when people suffer from pain in the back of the heel it is related to overuse or inflammation of the Achilles tendon. When people suffer from plantar fasciitis pain, it can be caused by a person stepping on a large stone or rock which bruises the heel, or it can be caused by inflammation of the plantar fascia. A heel that is hurt by a sharp object will heal on its own over time.

The repetitive stress of certain conditions or activities commonly leads to plantar fasciitis. Repetitive pressure on the feet from jobs or activities that require prolonged walking or standing on hard on irregular surfaces - or running and exercise - can also lead to wear and tear on the plantar fascia. Aggravating factors, such as being overweight or having poorly cushioned shoes can also add to the cause of plantar fasciitis. The natural aging process (whoopee for me) may also cause tissue in the heels to weaken over time and/or promote wear and tear.

Let us begin the discussion with a short explanation on what is plantar fasciitis. The human foot consists of plantar fascia, which is a thick and fibrous band of tissues, that originate from the lowermost surface of the heel bone and stretches along the sole of the foot, towards the toes. Plantar fasciitis is an inflammatory and painful condition of the plantar fascia. It is characterized by heel pain of light or severe nature. Plantar fasciitis is a commonly found condition in the United States and it has been observed that, every year almost two million Americans encounter plantar fasciitis.

Pain from plantar fasciitis can cause sharp pain on the bottom of the foot and can affect quality of life in many people. The American Academy of Podiatric Sports Medicine states that heel pain is the most common complaint to podiatric practitioners throughout the country. According to the National Library of Medicine, treatments for heel pain include rest, medicines, exercises and taping. They also mention that surgery is rarely needed in cases of heel pain caused by conditions like plantar fasciitis. Some exercises can be performed at home without a lot of equipment and can help with the symptoms associated with plantar fasciitis. Anatomyplantar fasciitis shoes

X-rays of the heel can oftentimes show calcifications within the Achilles tendon at its insertion site or calcifications on the bottom of the calcaneus near the insertion of the plantar fascia. The first exercise involves facing a wall and having your feet flat on the floor with your toes approximately 12 to 15 inches from the wall. At this point, keeping your heel flat against the floor, one must lean into the wall and touch their chest against the wall and hold the stretch for approximately one minute. The ideal angle for the bottom of the foot should be 45 degrees.

The foot is a very complex mechanical structure. Each foot is assembled from 26 bones, 33 joints, more than a 100 muscles, ligaments, tendons and nerves. The human foot system is even more complicated and is changing in every individual. The plantar fascia band part in the foot mechanism is to keep the foot longitudinal arch structure. It operates almost like a bow-string. But this structure is kept also by the other components of the foot particularly the foot's small muscles. If you practice your feet this whole structure will get stronger. Stronger foot muscles can assist the plantar fascia keeping it from another injury.

Patients with low arches theoretically have a decreased ability to absorb the forces generated by the impact of foot strike. 5 The three most commonly used mechanical corrections are arch taping, over-the-counter arch supports and custom orthotics. Arch taping and orthotics were found to be significantly better than use of NSAIDs, cortisone injection or heel cups in one randomized treatment study. 8 Arch taping was cited by 2 percent of patients as the treatment that worked best for plantar fasciitis in another study. 3 A single taping treatment is much less expensive than an over-the-counter arch support or an orthotic.

Patients try various remedies for the treatment of plantar fasciitis. Surgery is only the last option. PF insoles are proven to work for several people. Insole treatment is now considered a long-lasting solution to PF and various other foot related problems. Insoles very gently reposition your feet by acting on the arches. A good arch support is fitted inside your shoe according to a prescribed plan of use recommended by your podiatrist. Over a period of time, the arch supports become gentler which helps in the healing process. With the progression of the therapy, the focus is on maintaining the right alignment instead of changing it.

Plantar fascia is the name given to the band of thick and fibrous tissue which acts to keep the foot's bones in place. Cited as one of the most common of complaints in the foot, plantar fasciitis can be caused by several risk factors, including running, foot arch issues, obesity and sudden weight gain. These symptoms occur more commonly in middle-aged men than any other age group. Plantar fasciitis is often linked with heel spurs, but are not the cause of spurs, nor are they caused by spurs. The condition can manifest in feet with or without heel spurs.plantar fasciitis stretches
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