Meralgia Paraesthetica

 Meralgia Paraesthetica; (Iliotibial Band Syndrome) is a condition that causes pain, tingling, numbness and burning sensation outer side of the thigh. It is caused due to prolonged lying down or sitting in particular posture of the lower limbs. It is not related to any nerve involvement as believed so for. Like planter fascitis it is an affection of the thick fibrous deep fascia 'Iliotibial Band' with the adherent overlying skin. This condition usually affects one of the lower limb in adults age group of 40 to 70 years and above. In severe cases the symptoms extend proximally up to gluteal region and distally unto the Gordy's tubercle on outer side of lateral condyle of tibia. The problem affects the person's day to day activities for weeks, months or even years till the habit of posturing is not corrected.

On examination the person usually has limitation of abduction and external rotation (circumduction) of the hip joint and inability to sit cross legged properly. In case this posturing is continued often knowing or unknowingly for long periods, it would cause some pathological changes of the hip joint of the affected side causing SYMPTOMS WHAT WE KNOW NOW AS FAI (FEMORO-ACETABULAR IMPINGEMENT). The diagnosis is usually self evident. However, one has to rule any spine and hip problem. IN case of any doubt Pelvis and LS spine x-rays become necessary.

Etiopathology: In particular ways of prolonged sitting and/or lying posture, the iliotibial fascia with overlying adherent skin of affected lower limb  gets stretched to its extreme, so much so their blood supply gets disturbed; and while resting overnight the ITB develops hyperaemia and edema of the soft tissues. When he gets up in the morning and and tries to extend his affected lower extremity, he feels dull aching pain and burning sensation on outer side of thigh from the trochanteric region down to the knee. These symptoms are often more marked around sacroiliac region and buttock on the affected side. Severity of symptoms depends on time period and degree of stretching suffered.

   To understand the stretching caused by the postures, one has to understand the anatomy of ITB in relation with the position of hip and knee. ITB has fixed bony attachments to the Gerdy's tubercle of  lateral condyle of tibia distally. Its proximal end is attached to anterior superior iliac spine directly through the Tensor fascia Lata and its covering fascia; and superoposterialy to the sacroiliac bones  through the gluteus maximus muscle and its covering fascia almost at 50 to 70 degree angle inclined posteriorly. When a person lies on a bed and or sits on a chair in such a way that one of his thigh gets forcibly adducted; and the ITB gets stretched to its extreme due to the tenseness of gluteus maximus muscle with its fascial covering. Weight of the other limb usually stabilizes the posture and also add to ITB's tenseness, However, throughout in this posture the TFL remains relaxed. After having a few incidences of this posturing the person start having vague buttock pain more so around SI joint and symptoms over the outer side of thigh and knees continue to increase. If the posture is being adopted often for weeks, months and even for years, the symptoms continue with varying degree of severity, (Fig. demonstrating the postures).

                             
                                                            

 Fig. I: Anatomy of  ITB Rt. side.                  Fig. II: Lie Down Posture: Rt. side will be affected.               Fig. III:  Sitting Posture: Rt. side will be affected.

Treatment: It is advisable to discontinue henceforth the above mentioned prolonged posturing start exercises to mobilizes his spine and lower limb joints. Physiotherapy is necessary in case the movements show some  limitation. Analgesics and liniments are needed to relieve pain and inflation.  Orthopaedics treatment is reqired incase patient has already developed FAI'

Planter fascitis

 Planter fascitis (Pain Underside of HEEL): Planter fascitis causes pain adjacent to its attachment underside the heel bone (red arrow). Usually only one foot is affected. While patient is non weight bearing he does not have any pain or have some burning sensation in the sole; but when he starts walking, the first step of weight bearing on the affected foot he gets agonizing heel pain. In severe cases pain recurs on every step of weight-bearing and may have persistent burning sensation of the sole even while resting  On examination tenderness can be elicited just anterior to the medial tuberosity of the calcaneus. Planter fascitis affects adults of any age and sex. It affects usually persons involved in sedentary and or laborious jobs like teachers, housewives, construction workers, guards etc. where their work require to them to remain prolonged standing without much movement.. All sport persons usually do not get this problem. Diagnosis is usually self evident. Rarely Radiological and/or sonographic tests may be required to rule out other medical conditions. A lateral X-ray of the affected foot at times may show unrelated minor calcaneal spur.

Anatomy of the Planter Fascia (aponeurosis-fig.): planter aponeurosis like palmer aponeurosis consists of thick bands of fibrous tissues extending longitudinally deeper and adherent to the thick skin of the mid sole (yellow line in figure). It's thickened and compact posterior end is attached to the  medial tuberosity on the bottom side of the heel-bone (calcaneus) and fans out anteriorly to divide into five bands one for each toe and gets attached to deep inter-metatarsal ligaments and divide into two slips to insert to both sides of the planter ligament of the adjacent MP joint..

Functions of planter aponeurosis: 

1. It covers and protects soft tissue (neurovascular, muscular and ligaments) lying on bottom side of the tarsal bones.

2. It helps in maintaining the medial arch of the foot between its anterior and posterior bony attachments.

3. Planter Fascia remains relaxed during the swing phase and the heel strike phase; but remains stretched like bow-string to maintain medial longitudinal arch during stance phase and during push (toe) off phase to work like a windlass for the toes to get firm grip of the ground.

Cause of pain: During walking the  relaxed planter fascia in swing phase and heel strike phase receives satisfactory blood supply; but during stance phase and push off phase when the fascia remains stretched its blood supply is gets blocked. These processes get repeated with every step of walking. Similarly, as there is no heel strike and no stance phase; the swing phase and push off phase alternates processes gets repeated while running. But when a person remains standing for long duration almost continuous, the planter fascia does not get adequate blood supply and the part of fascia with thick condensed collagen fibers close to its attachment to calcaneus which also bears major part of the body weight gets affected most. The anoxic fascia develops hyperemia with local edema when the person rests for some time. This appears to be the cause of pain under close to the heel when the person get up and starts weight bearing again.

Treatment of PLANTER FASCITIS:  treatment of planter fascitis is simple. Patient  has to avoid continuous weight bearing on the affected foot. Within 3-4 days pain will subside.  For initial 3-4 days he /she can take some analgesic and apply  liniment for pain relief. Heel pain may recur in case he/she restarts continuous standing  for long duration. There is no need for any appliance or any local injection as routinely prescribed.

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HAGLUND'S SYNDROME: AN EATIOLOGICAL ANALYSIS

Patient's complain: Retrocalcaneal pain and swelling persisting for weeks, months and some time for years. Insidious in onset. Pain varies in intensity and swelling varies in size depending on patient's day to day activities. patient finds difficulty in squatting and climbing up & down stairs. High heel shoes or walking on toes somewhat relieves pain.

On examination: retrocalcaneal swelling is localized at the level of superior third of the posterior tuberosity of the calcaneus. As swelling is deeper to the TENDO-ACHALIS it is prominent on the sides of tendon and is not seen over it. Swelling is less obvious when ankle is planter flexed / patient stands on toes and it becomes prominent when ankle is dorsiflexed. In acute onset , swelling is somewhat warm and tender even over the tendoachalis more so when tendon is relaxed.

Anatomic study of posterior surface of calcaneus: It is almost rectangular. Its surface  is convex more in vertical axis than in horizontal and its margin on all side is rounded. In vertical plane its surface is divided in three parts. The middle part with irregular surface formed by a horizontal bony ridge somewhat raised from the smooth proximal  part while it merges with the smooth surface of the distal part of the  posterior surface of calcaneus.(location of bursa shown with red marker in Fig.1). Tendoachalis tendon becomes thick aponeurotic as it reaches the posterior surface of calcaneus insert to the raised middle horizontal ridge but, the aponeurotic tendon remains separated from the smooth proximal bony surface by a bursa.

Pathological anatomy: Due to some odd process natural anatomy of the posterior surface of the  calcaneus changes and develops a bony protuberance at its superior angle. It may be natural or due to infection, trauma, benign growth etc. (shown with red marker in Fig.2) so much so it starts rubbing and pinching the anterior surface of the TA irritating the in between bursa which becomes inflamed i.e. bursitis leading to bursal swelling due to its thickened wall distended with inflammatory fluid causing pain and swelling which pops on both medial and lateral sides of the tendon. The swelling becomes more prominent whenever TA tendon tightens on weight bearing more so with dorsiflexion of the ankle while squatting, walking, climbing up down stairs, going uphill etc.

Treatment of the Haglund's syndrome: temporarily pain and inflammation can be reduced with rest and patient is asked to use high-heel footwear while weight bearing. To cure the condition the bony protuberance has to be surgically excised without damaging TA insertion and avoid wait bearing till the surgical wound has healed properly.

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Insertion of  Achilles tendon: -As the tendo-Achilles approaches its insertion the tendon flattens to expand horizontally, and become thick aponeurotic to insert to the whole width of the ridged middle surface. The flattened tendon at its insertion forms an acute angle with the proximal smooth surface and the triangular space thus formed is lined with a  synovial sheath. This arrangement facilitates smooth sliding of  flattened end of TA over the proximal part of calcaneus during the dorsiflexion of  the ankle joint. During active planter flexion the acute angle between flattened TA and the proximal part of calcaneus somewhat opens up and in dorsiflexion the space gets almost totally reduced so much so the tendon almost rubs against the smooth superior part of the posterior surface of calcaneus. Thus, presence of any bony protuberance and or roughness in the superior part of posterior surface pinches the anterior surface of  flattened TA when ankle is dorsiflexed irritating the bursa between the bone and the tendon. This repeated movements of the ankle causes  inflammation of the retrocalcaneal bursa which gets filled with synovial fluid causing pain and swelling. As the bursa is deeper to the TA, the swelling pouches of synovial fluid are formed on either sides of  the tense TA and not over it giving a dumb-bell appearance just proximal to insertion of TA. The pain gets aggravated and the dumb-bell swelling on the sides of TA  becomes tense and prominent on dorsiflexion and is relieved partially or fully with planter flexion of the ankle joint.(Fig.2)