Shoes and Plantar Fasciitis – Good Shoes, Bad Shoes


The plantar fascia is a ligament that supports the foot.  It spans from the base of the heel to the bases of the toes.  It is a strong ligament.  It is strong in tensile strength. Tensile strength means pulling strength.  If one stretches, for example, a wire, the point at which the wire breaks is called it’s tensile strength.  It is hard to break a wire by stretching it but it can easily break if one twists the wire.  The plantar fascia is similar – strong in tensile strength but weak in torsional or  twisting strength.

How does twisting of the fascia occur.  The answer is side to side motion.  When the heel strikes the ground, the foot lowers to ground, rolls inward in a motion called pronation.  It is the joint below the ankle joint called the subtalar joint that allows pronation.  Pronation is a twisting motion.  Some pronation is normal but too much or overpronation causes excess torsional stress on the fascia.  Chronic repetitive twisting of the fascia causes damage.

If one steps onto a pillow, the foot pronates more, the arch lowers more.  Many shoes sold nowadays are like pillows – very soft.  Softness sells shoes.  The area of the shoe from the heel to the ball of the foot should have some rigidity but flexibility should exist at the base of the toes.  Shoes, historically, have 3 parts to the sole: the insole, the midsole and the outsole.  The insole and outsole are visible but the midsole, when present, maintains the integrity of the shoe and support for the foot.  The midsole contains the shank.  The shank is a still plate that prevents twisting of the shoe in the middle and is what protects the heel, arch and plantar fascia.  Steel shanks were invented over 800 years ago.  So shoemakers were aware that the shank was a necessary part of shoe construction for centuries.  It is only more recently that shanks were left out of the shoemaking process.  Shanks do not need to be made out of steel.  Newer shank materials include fiberglass, carbon graphite, hard plastics or even kevlar.


Steel shank boots

Steel shanks may still be found in certain work boots and other types of boots such as cowboy boots.

How can one tell if a shoe has a shank?  Try bending the shoe in the middle.  It should bend at the ball of the foot only.



Regenerative medicine as a treatment for heel pain caused by plantar fasciosis.

IStock-821148970- regenerative med

Regenerative medicine is an effective option for treatment of plantar fasciosis.  Plantar fasciosis is a degenerative condition, not an inflammatory condition.  Plantar fasciitis that is left untreated or partially treated can become chronic. As the fascia continues to thicken due to chronic inflammation blood supply to it is reduced. Fascia does not have it’s own blood supply but is supplied by muscles nearby. As the fascia continues to thicken, there is reduced blood supply to its central portion which becomes scar tissue like – stiff and painful. 

We have discussed ESWT and Topaz procedure as treatments for plantar fasciosis.  Use of growth factors originating in stem cells can effectively treat plantar fasciosis.  The source of the growth factors used to regenerate good fascia is donated amniotic fluid.  The fluid does not have contain the actual stem cells but the substances that trigger new tissue growth.

Human amniotic membrane (HAM) consists of two conjoined layers, the amnion and chorion, and forms the innermost lining of the amniotic sac or placenta. When prepared for use as an allograft, the membrane is harvested immediately after birth, cleaned, sterilized, and either cryopreserved or dehydrated. Many products available using amnion, chorion, amniotic fluid, and umbilical cord are being studied for the treatment of a variety of conditions, including chronic full-thickness diabetic lower-extremity ulcers, venous ulcers, knee osteoarthritis, plantar fasciitis, and ophthalmic conditions. The products are formulated either as patches, which can be applied as wound covers, or as suspensions or particulates, or connective tissue extractions, which can be injected or applied topically.

Fresh amniotic membrane contains collagen, fibronectin, and hyaluronic acid, along with a combination of growth factors, cytokines, and anti-inflammatory proteins such as interleukin-1 receptor antagonist. There is evidence that the tissue has anti-inflammatory, antifibroblastic, and antimicrobial properties. HAM is considered nonimmunogenic and has not been observed to cause substantial immune response. It is believed that these properties are retained in cryopreserved HAM and dehydrated HAM products, resulting in a readily available tissue with regenerative potential. In support, one d-HAM product has been shown to elute growth factors into saline and stimulate the migration of mesenchymal stem cells both in vitro and in vivo.

HAM is an established treatment for corneal reconstruction and is being evaluated for the treatment of various conditions, including skin wounds, burns, leg ulcers, and prevention of tissue adhesion in surgical procedures. Additional indications studied in preclinical models include tendonitis, tendon repair, and nerve repair. The availability of HAM opens the possibility of regenerative medicine for a wide variety of conditions.

The incorporation of amniotic membranes tissues can decrease fibrous collagen deposition scar formation in vitro and modify inflammatory responses of tenocytes.52 Compared with adult wound healing, fetal wound healing has the ability to form highly aligned and organized fibers with minimal scar formation,53 suggesting that fetal tissues and the fetal environment may be uniquely capable of supporting tissue regeneration. Therefore, one approach to recapitulate fetal healing is to use ECM-based biomaterials that originate from environments with anti-inflammatory and antimicrobial properties, such as amniotic tissue. It was shown that when amniotic membrane tissue was incorporated into tenocyte-laden collagen-glycosaminoglycan scaffolds, cells exhibited increased metabolic activity in both basal and proinflammatory environments (induction with IL-1β) compared with scaffolds without amniotic tissue.52 In addition, the addition of amniotic membranes also downregulated the gene expression of the proinflammatory molecules tumor necrosis factor-α and matrix metalloproteinase-3 in tenocytes, indicating that this biomaterial could alter the inflammatory response associated with scar formation in tendon healing to better mimic fetal soft tissue healing.52 Methods of incorporating hyaluronic acid (HA) have also been explored to reduce scar formation, as HA is known to play a role in chronic wound healing by promoting cell proliferation and motility.54,55 As a critical component of several orthopedic tissues including cartilage and synovial fluid, HA contributes both mechanical properties as well as the ability to regulate cellular activity through interaction with growth factors and binding of cell surface receptors, such as CD44. In particular, HA is an ECM component that has been detected and quantified in dHACM tissues and may play a role in improved soft tissue healing.56 Thus, the use of amniotic membranes that contain HA could potentially be an effective method to help modulate the inflammatory environment to decrease scar formation during tendon and ligament healing.

  1. Hortensius RA, Ebens JH, Harley BA. Immunomodulatory effects of amniotic membrane matrix incorporated into collagen scaffolds. J Biomed Mater Res A. 2016;104:1332–1342.
  2. Eming SA, Krieg T, Davidson JM. Inflammation in wound repair: molecular and cellular mechanisms. J Invest Dermatol. 2007;127:514–525.
  3. Price RD, Myers S, Leigh IM, et al. The role of hyaluronic acid in wound healing: assessment of clinical evidence. Am J Clin Dermatol. 2005;6:383–402.
  4. Liu Y, Skardal A, Shu XZ, et al. Prevention of peritendinous adhesions using a hyaluronan-derived hydrogel film following partial-thickness flexor tendon injury. J Orthop Res. 2008;26:562–569.
  5. Lei J, Priddy LB, Lim JJ, et al. Identification of ECM components and biological factors in micronized dehydrated human amnion/chorion membrane. Adv Wound Care. 2016;6:43–53. In press.

 For treatment of plantar fasciitis, a prospective, randomized, blinded clinical trial with 45 patients revealed that micronized dHACM administration is a viable treatment option to decrease pain. Micronized dHACM was first reconstituted in 0.9% saline at 0.5 or 1.25 cc. For administration of either the dHACM treatment or saline control, patients received a 2 cc injection of Marcaine to the medial origin of the plantar fascia, followed by an injection of 0.9% saline control or 0.9% saline containing the reconstituted micronized dHACM.

  1. Zelen CM, Poka A, Andrews J. Prospective, randomized, blinded, comparative study of injectable micronized dehydrated amniotic/chorionic membrane allograft for plantar fasciitis—a feasibility study. Foot Ankle Int. 2013;34:1332–1339.

How To Wash Away Heel Pain With Water

San Antonio Podiatrist Washes Away Tough Cases of Heel Pain With Water


Heel pain is often caused by plantar fasciitis which is an inflammatory condition of the plantar fascia. The plantar fascia is a tough fibrous band of tissue that starts in the heel bone and goes forward across the arch to attach to the bases of the toes.  The fascia is a critical supporting structure of the foot but can become overused in sport and work.  The fascia is strong in certain respects but weaker in others.

The plantar fascia has tremendous tensile strength but is weaker when subjected to torsion or twisting. Torsional strain of the fascia may be due to unsupportive shoegear or faulty foot mechanics.  Overpronation is a rolling in of the foot and oversupination is a rolling out of the foot, both of which can lead to strain of the plantar fascia.

Symptomatic relief of plantar fasciitis may be obtained by massage, anti-inflammatories or perhaps use of cortisone but it is more important to identify and treat the underlying causes so that permanent relief can be achieved.

Plantar fasciitis, left untreated or treated symptomatically only, can eventually become plantar fasciosis which is more difficult to treat.  Fasciosis is a degenerative process of the fascia in which the fascia becomes thickened and scarred over time.  Only imaging via MRI or diagnostic ultrasound can determine the presence of plantar fasciosis.

New treatments have been developed over the years to treat fasciosis including use of ESWT or extracorporeal shockwave therapy, TenexTX which uses ultrsasound energy to removed the diseased tissue and more recently the HydoCision TenJet.  TenJet uses an ultrasound guided stream of water to remove the diseased tissue of plantar fasciosis in a minimally invasive fashion. 

TenJet technology uses a special wand that is placed through a small opening in the skin and, using ultrasound guidance,  delivers a controlled supersonic stream of saline (salt water) that essentially washes away the diseased tissue while leaving the good tissue undamaged.  The procedure is generally performed in an outpatient setting under local anesthesia and takes about 15 minutes.  Patients may walk immediately after the procedure and return to normal shoegear within 24 hours.   See

Dr. Ed Davis is a board certified podiatrist in San Antonio who has been an early adopter of advanced technologies to treat heel pain. He started using ESWT in 2002, the Topaz procedure in 2008 and can explain when and why to use the newer technologies.  



Stress Fractures of the Calcaneus (Heel Bone)



Stress fractures are cracks in bones that occur from chronic repetitve trauma. It is relatively easy to understand how bones are broken in trauma such as falls or collsions with objects as there is a readily identifiable event as the culprit.


Consider a paperclip that, after being bent several times, will break in two. If it takes 4 bends to break a paperclip then a paperclip that has been bent three times, that appear to be in one piece is not a normal paperclip since one more bend will break it.


Human bones, when loaded or bent repeatedly beyond their capacity may form small cracks which can eventually break. The small cracks are generally not visible on x-ray. The difference between bone and the metal of a paperclip is that bone is continually healing or building up on the area of stress. If the building up or repair process exceeds the damage caused by repetitive stress, then there is not an issue.


The human heel strikes the ground at each step with about 1.5 times body weight during normal walking. Running can increase the force to 2 to 3 times body weight. Shoes with poor heel protection, poor running form, shoes with lack of shanks, or faulty foot mechanics can significantly increase stress and strain on the heel bone.


Pain from calcaneal or heel bone stress fractures may cause pain througout the day unlike plantar fasciitis which is more noticeable after arising in the morning or after rest. Swelling or bruising may be present. One simple test is known as the “squeeze test” in which one can squeeze the bottom portion of the heel bone which, if painful, may be a sign of a calcaneal stress fracture.


Stress fractures of the heel bone, like other stress fractures, are often diagnosed clinically as imaging may not readily reveal the fracture. Radiographs are often negative when stress fractures occur so early immobilization via CAM walkers (cast boots) or casts may be considered while awaiting more definitive imaging with MRI or CT scans.


The good news is that the heel bone tends to heal well once immobilization has been provided. It is important to recognize the underlying causes of the stress fracture and take measures to prevent recurrence.


Calcaneal stress fracture1


For more information visit:  Podiatrist San Antonio

MEHPS or Multiple Etiology Heel Pain Syndrome

We have discussed the importance of obtaining an accurate diagnosis as the critical first step in effectively treating heel pain on this blog.  Also, the blog contains lists of common causes of heel pain.  It is certainly possible for heel pain to have more than one cause in a patient.

I just completed a fascinating course taught by Stephen L. Barrett, DPM called the Heel Pain Boot Camp in Scottsdale, Arizona:  Dr. Barrett is an internationally acclaimed expert on the subject of heel pain and has authored a number of publications on the subject. 

Dr. Barrett discussed the concept of the multifactorial causes of heel pain in 2006 in this article:     Importantly, he advised practitioners, in the article, to broaden their approach to the diagnosis and treatment of heel pain.  Old paradigms take time to change but hopefully his Heel Pain Boot Camps will accelerate the understanding and application of these concepts.

We are taught, in our training, the motto:  "If you hear hoofbeats, don't think of zebras."  That advice means that if a patient has a symptom, always start with the most common cause, not the more "obscure" or exotic causes.  It is true that plantar fasciitis represents about 93% of heel pain.  Nevertheless, true plantar fasciitis, which is an inflammation of the plantar fascia is often self limiting and relatively easy to treat.  It is for that reason, that podiatrists may not see that much plantar fasciitis....we see patients with heel pain that has persisted and is not self limited.  In other words, the patients we see with heel pain probably represent a population whose heel pain causes go beyond simple plantar fasciitis.

Traditionally, patients who present with heel pain may have an x-ray performed.  What does an x-ray show?  Bone and joint but not ligaments, tendons and nerves.  The plantar fascia is a ligament.  A ligament can be seen via diagnostic ultrasound or MRI.  MRI may be needed under some circumstances but not used routinely.  Office based diagnostic ultrasound (sonography) is thus the gold standard in the diagnosis of heel pain and should be the first test performed as opposed to x-ray.

High resolution ultrasound can also allow visualization of nerves with attention to the type of nerve problems that can cause heel pain such as tarsal tunnel syndrome, medial calcaneal neuritis and Baxter's neuritis.

It is not uncommon for us to encounter patients in our offices who have had heel pain for many months or even years and are convinced that they have the toughest cases of plantar fasciitis only to discover, upon sonographic exam, that their heel pain is not caused by plantar fasciitis.

Dr. Ed Davis, Podiatrist San Antonio, 210-490-3668

Heel pain may be caused by a tight or contracted Achilles tendon.

Achilles heel iStock_000047636266_Large (2)
Tight or contracted Achilles tendon can lead to plantar fasciitis or heel pain.

The ankle joint allows the foot to move up and down (dorsiflexion and plantarflexion). The foot needs to be able to move up on the leg by about 15 degrees in order to allow normal gait. Upward motion of the foot on the leg is called dorsiflexion.

Lack of adequate dorsiflexion range of motion is called functional equinus. The term “equinus” is derived from the Latin “equus” for horse. A horses hoof points downward without upward motion.

What causes functional equinus?

      1. Congenital causes: The Achilles tendon and muscles that make up the Achilles tendon in the leg may be contracted due to position of the baby in the womb.

      2. Biomechanical causes: The Achilles tendon is created by two large muscles in the back of the leg, the Gastrocnemius and Soleus muscles. Those muscles often overpower the smaller muscles in the front of the leg leading to an imbalance.

      3. Neurologic causes: Any neurologic condition causing weakness in the anterior muscles group (muscles in front of the leg) can lead to overpowering of the posterior muscle group (the muscles making up the Achilles tendon) allowing the posterior muscles to pull the foot into equinus.

      4. Poor shoegear choices: Long term use of high heels can cause shortening of the Achilles tendon. Additionally, use of poorly supportive shoegear may lead to compensatory tightening of the posterior muscle group.

      5. Bony causes: Bone spurs in front of the ankle or ankle joint deformity caused by fractures can reduce dorsiflexion at the ankle.

      6. Iatrogenic causes: “Iatrogenic” means that the condition is caused by medical care. For example excessive tightening of the Achilles tendon after surgical repair, ecessive scar tissue or poor positioning during casting can lead to functional equinus.

The Achilles tendon attaches to the back of the heel bone and the plantar fascia attaches to the bottom of the heel bone. A tight Achilles causes tightening of the plantar fascia. Additionally, if the foot cannot adequately dorsiflex (move upward) on the leg as one pushes off, then one must compensate, finding a different way to achieve that motion.

The joint beneath the ankle joint is the subtalar joint. The subtalar joint is responsible for side to side motion, inversion (turning in) and eversion (turning out). The motion at the subtalar joint is not pure eversion/inversion but when one turns the foot out, it also moves up (dorsiflexes) a bit. That motion is known as “pronation.” The opposite motion is known as “supination” which is a combination of inversion and pointing down (plantarflexion). If there is functional equinus then the foot will compensate by overpronating during push off (propulsion). Pronation in that manner will lead to a twist of the middle of the foot with each step and a twisting of the fascia. Chronic repetitive twisting of the fascia causes it to become thickened and painful. A rigid shank in the shoe can signficantly reduce the problematic twisting or torsion of the fascia.

Patients with functional equinus often tolerate orthotics poorly or obtain inadequate relief from orthotics because such devices attempt to block the compensatory motion needed for the patient to push off. It is necessary to treat the functional equinus before the orthotic can work.

Treatment of functional equinus.

  1. Manual therapy. This refers to the type of physical therapy in which the practitioner manual works to elongate the Achilles. The Achilles does not truly elongate but such elongation occurs in the region immediately above the Achilles known as the Gastrocnemius aponeurosis. The Gastrocnemius aponeurosis is a flat membrane below the Gastrocnemius muscle belly (the muscle that forms the back of the calf).

  2. Night splints. These are devices that look like boots, oftern worn at night, which gradually lead to elongation of the contracted Gastrosoleus-Achilles complex, restoring dorsiflexion range of motion. It is very important that these be adjusted properly and patients be provided with adequate instruction on their use. We see a large number of patients who have obtained such devices and attempts to use such devices without such information.

  3. Surgical treatment. Achilles tendon lengthening. This is rarely needed for mild to moderate contracture of the Achilles but is indicated for more severe degrees of contracture or, at times, when there is a neuromuscular issue that need be addressed.


Dr. Ed Davis  Podiatrist San Antonio  210-490-3668

Tenex TX Procedure - A New Minimally Invasive Option for Treatment of Heel Pain

Recalcitrant or tough cases of plantar fasciitis are often due to a degenerative process of the plantar fascia, known as Plantar Fasciosis.  Such cases may have been treated by invasive surgical techniques in the past but now there are non-invasive or minimally invasive options.

1) ESWT or extracorporeal shockwave therapy involves the use of acoustic or pressure waves applied in an office setting to induce healing the diseased plantar fascia. It is non-invasive.

2) The Topaz Procedure is a minimally invasive technique that involves use of a radiofrequency ablation "wand" which atraumatically removes the diseased tissue.

3) The Tenex TX Procedure.  A relatively new procedure in which a wand which uses ultrasound energy is inserted percutaneously (through a tiny opening in the skin) and the abnormal tissue of the fascia removed under imaging, typically sonography.  The Tenex TX procedure may be potentially less traumatic than even the Topaz Procedure since the diseased tissue can be more precisely targeted.


Orthotics and Heel Pain

The plantar fascia is a flat broad ligament that acts as a strut, orginating at the base of the heel and extending across the bottom of the foot to attach at the bases of the toe joints. It is narrower at the heel and widens as it goes forward.

The plantar fascia is very strong in terms of tensile strength (pulling strength) but is prone to damage when twisted either excessively or repetitively, AKA torsional strain. Too much pronation (inward rolling) of the foot or too much supination (outward rolling) is what can cause such twisting of the fascia. That is a bit of an oversimplification because when the back of the foot rolls in, the front of the foot rolls out in response.

Orthotics are devices which change the mechanics or function of the foot. There is not a rule or strict definition of an orthotic so vendors can apply the label “orthotic” to almost anything one can place in a shoe, from insoles to arch supports.

There are three broad categories of foot orthotics, prefabricated or OTC orthotics, customized orthotics and custom orthotics.

1) Prefabricated or OTC orthotics: Inserts that are mass produced and sold by shoe size. They primarily act as arch supports and can be helpful in reducing overpronation. Some of our favorite brands are Powerstep, Superfeet, Sole and Redithotics. The cost of prefabricated orthotics ranges from about $15 to $50 and can be found at retail outlets and occasionally at medical provider's offices. There are some types of prefabricated orthotics being marketed as “custom” at retail outlets for substantially higher prices so “buyer beware.”

2) Customized orthotics: These are prefabricated orthotics that have been molded, modified or changed by a healthcare professional to make them work better. 

3) Custom orthotics: This refers to orthotics that are provided by a healthcare professional, often a podiatrist. The podiatrist first performs a biomechanical exam of the feet and legs to determine the optimal prescription, then, takes a mold of the foot while holding it in a semi-corrected position. Keep in mind that such a mold cannot be made by having the patient standing because the foot will tend to go to the position that is causing problems.

For a more detailed explanation of foot orthotics visit our website:


Podiatrist San Antonio discusses alternate causes of heel pain

Most heel pain is caused by mechanical issues such as heel pain due to plantar fasciitis.  There are numerous causes of heel pain so getting a proper diagnosis is important.  I see a number of patients with heel pain that they beleive is caused by plantar fasciitis but the symptoms are not relieved by common treatments for plantar fasciitis.   Such cases often involve other causes of heel pain.

Here is a partial list of heel pain causes:

1) Gout       Gout is a metabolic disease in which the body collects too much of a waste product, uric acid.  Uric acid levels can be raised because the body makes too much uric acid or because it has difficulty excreting it.

2) Rheumatoid arthritis    Rheumatoid arthritis is a form of arthritis due to antibodies formed to the bodies own tissues, most commonly tissues in joints.  It is a fairly common cause of heel pain.

3) Reiter's syndrome, ankylosing spondylitits and psoriatic arthritis   This group of arthritic conditions are known as HLA-B27  arthritides due to the gene involved and can cause heel pain.

4) Osteoid osteoma  This is a benign tumor of the heel bone that often causes heel pain at night.

5) Stress fracture   A stress fracture is a fracture, often a hairline fracture, that is caused by overuse.  The best way to visualize a stress fracture is to take a paper clip and bend it several times. It may break in two by the fourth bend but consider if that paper clip is normal after it has been bent 3 times.  A magnifying glass or microscope would show tiny fractures in the paperclip at that point.  Unlike the paper clip, our bodies are building up tissue and breaking them down.  If the breakdown process exceeds the repair then stress fractures can occur.  Stress fractures are more likely to occur when bone is weakened as in osteoporosis or osteopenia.

6)  Infections   Infections of the heel bone can occur due to direct trauma such as puncture wounds or spread from nearby wounds.   Infections in other parts of the body such as dental infections can spread by the blood to the heel.

Heel pain in youth - calcaneal apophysitis or Sever's disease

Heel pain is less common in children than adults and the causes are usually different.  It is unusual for plantar fasciitis to occur in youth.

The most common cause of heel pain in the approximately 9 to 14 year old age group is calcaneal apophysitis or Sever's disease.

The heel bone or calcaneus has a growth plate, that is, an open area of growing tissue that creates bone growth located at the posterior (back) area where the Achilles tendon attaches.  A growth plate is termed an "epiphysis" and a growth plate to which a tendon attaches is known as an "apophysis."   Inflammation at the apophysis of the heel bone is called "calcaneal apophysitis."

An x-ray of the heel bone in a child shows two areas of bone, the main part of the heel bone and a portion in the back with "space" in between the two bones.  That space gets smaller as the two bones grow toward each other.  Eventually, the space between the two bones disappears and the two bones become one.  That occurs between the ages of 13 to 15 although there is some variability.

The area between the "merging" heel bones or calcaneal apophysis appears most sensitive to overuse injury within 18 months to fusion, in my experience.

Most patients we see with calcaneal apophysitis present with certain factors in common:

1)  They are active in school sports; often soccer, basketball or football.

2)  A tight heel cord or Achilles tendon is frequently present.

3) They often display subtalar joint overpronation, that is, the foot/heel/arch tends to roll in excessively when walking and standing.

The popularity of school soccer has led to an increase in cases of calcaneal apophysitis in my practice.  Soccer shoes provide little protection for the heel and little support.

Here are some potential treatments to try before seeing a pediatric podiatrist:

1) Stretching of the Achilles tendon.  Should be done gently, especially if pain is present.

2) Use running shoes in lieu of soccer and basketball shoes when possible, that is, when not playing the game or in practice.

3) Consider a good OTC insert such as Powersteps or Superfeet.

4) Rest, icing and use good judgement.   Playing through pain can lead to further injury.


Seek professional treatment if self care is not effective.  The key issue is to identify the causes of the heel pain and target treatment to alleviate the causes.  If there  is excessive Achilles tightness or contracture then a course of manual therapy can be effective.  Significant overpronation is treated with a prescription orthotic.  We general use an orthotic design which has a deep heel cup.  The heel cup is the portion of the orthotic that surrounds the heel.  The orthotic may have a rearfoot post which is a wedge that stabilizes the heel, neutralizing excessive motion and stress on the growth plate.


 For more information on pediatric foot problems, visit:  Childrens Foot Doctor San Antonio