Health

How To Wash Away Heel Pain With Water

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

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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 https://www.hydrocision.com/products/tenjet/.

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)

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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


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

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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   https://www.southtexaspodiatrist.com/


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

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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


ESWT or extracorporeal shockwave therapy for the treatment of heel pain

 

ESWT is a treatment modality derived from renal lithotripsy in which high energy shock waves are used to break up kidney stones. The best way to understand the nature of a shock wave is to consider what happens when a tire blows out and the windows rattle afterwards. A acoustic wave or pressure wave is generated. The pressure waves that are used in lithotripsy or ESWT involve a very rapid increase in pressure followed by a rapid decrease in pressure.

Studies performed on kidney tissue via biopsies after renal lithotripsy noted a surprising finding, that the kidney tissue in the path of the shockwave became much healthier than surrounding tissue. That led to research as to how shockwaves applied with the right intensity and frequency can cause damaged tissue to repair itself. This technology led to a new industry, ESWT, which involves the use of controlled shockwave energy applied to damaged tissue to effect a repair.

Initially, studies led to somewhat variable results as the type of human tissue which ESWT has a beneficial effect on was not known. The key issue is to differentiate tissue that is inflamed from tissue which is degenerated. The term “fasciitis” means inflammation of the fascia and “tendinitis,” inflammation of a tendon. Our bodies appear to handle acute inflammation fairly well but have difficulty with chronic inflammation. Arteries which are chronically inflamed form plaque and clog; tendons which are chronically inflamed become thickened, filled with thick inflexible scar tissue which tends to crowd out the good tissue and reduce the blood supply to the tendon. That is true for fascia too. Fascia is connective tissue that surround muscle, giving it support. The blood supply (nutrition) to fascia generally comes from adjacent muscle tissue. When fascia becomes too thick or scarred, there is reduced circulation to it and it becomes diseased. We call that process, “fasciosis” if it involves the fascia or “tendinosis” if it involves tendon.

Dr. Harvey Lemont, a professor at the Temple University College of Podiatric Medicine, the school I graduated from, did a fascinating study which he published in 2003. He examined tissue samples taken from 50 patients undergoing surgery on the plantar fascia. Why were those patients being treated surgically? Because they had what was known to that point as “intractable plantar fasciitis,” in other words, heel pain caused by plantar fasciitis which did not respond to conventional conservative treatments. He found that the plantar fascia in those patients showed no signs of inflammation but degeneration instead, ie. Plantar fasciosis.

ESWT is a treatment for plantar fasciosis, not plantar fasciitis.

ESWT is a treatment for Achilles tendinosis., not tendinitis.

How does one know if plantar fasciosis or Achilles tendinosis is the cause of heel pain? The best way to know for sure is to perform imaging, either MRI or diagnostic ultrasound (sonography). We generally perform diagnostic ultrasound as it is relatively quick and inexpensive.

There are different technologies to provide ESWT which I will cover in a later post. I use the Swiss Dolorclast made by EMS as I feel that it provides excellent results at a reasonable cost.

Dr. Ed Davis – “heel pain doctor” in San Antonio

https://www.heelpain.pro/    heel pain doctor

 

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Baxter's neuritis, a common cause of heel pain

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Baxter's nerve
is another name for the inferior calcaneal nerve, which is a nerve branch which runs beneath the heel bone. Donald Baxter, MD, an orthopedic surgeon from Houston identified entrapment of this nerve branch as a potential cause of heel pain. Baxter's neuritis or Baxter's nerve entrapment may cause heel pain which can be confused with plantar fasciitis but there are some differences in the type of symptoms each causes.

Plantar fasciitis causes heel pain that is often worse after rest or after getting out of bed, also know as "first step" pain. A medical term for that is "post-static dyskinesia." Patients with Baxter's neuritis often do not experience first step pain but experience pain that seems to gradually worsen with weight bearing activities throughout the day.

Heel pain caused by plantar fasciitis generally subsides when one sits down and at night. Heel pain due to Baxter's neuritis may continue after one is off the feet. A burning pain may be encountered or a sharp shooting pain. Patients occasionally locate the pain at the edges of the heel, either the outer or inner edge.

Treatments which are typically effective for plantar fasciitis appear to have only mild effect on Baxter's neuritis.

Baxter's nerve enters the heel at a spot at the inside of the heel which when pressed, can send a shooting pain through the heel. There is no specific test for Baxter's neuritis so the diagnosis is often made clinically. The nerve may appear enlarged or swollen upon imaging by high resolution diagnostic ultrasound. Another way to help confirm the diagnosis is for the physician to numb the nerve with a very small amount of lidocaine, preferably with the help of diagnostic ultrasound. If the numbing completely resolves the heel pain, that is a strong piece of evidence that Baxter's neuritis is present.

Treatment options for Baxter's neuritis include the "Baxter procedure" which is a surgical nerve release of the nerve or neurolysis. "Neurolysis" here refers to a means by which the nerve can be desensitized to the extent that symptoms are resolved. Two means of neurolysis are commonly used: chemical and radiofrequency lesioning.

Chemical neurolysis involves injection of the nerve with a chemical, generally a dilute solution of alcohol which desensitizes but does not "kill" the nerve. Nerves are composed of different types of fibers: motor and sensory. The sensory fibers include fibers that transmit sensations of pressure, temperature and pain. The pain fibers are termed "type C unmyelinated" fibers. Myelin is the insulation around nerve fibers but pain fibers are "uninsulated" and thus the most sensitive. As such, use of a dilute solution of alcohol injected around the nerve can selectively treat the pain fibers. Such injections require considerable accuracy as the nerve is a small target and thus need be performed under imaging such as diagnostic ultrasound or sonography. Only a very small amount can be injected at a time so the procedure need be repeated. Typically 3 to 5 such injections at two week intervals.

Radiofrequency ablation refers to the use of an instrument commonly used to treat painful spinal nerves or facial nerves in conditions such a trigeminal neuralgia. Here is a link to a manufacturers' website: https://www.cosmanmedical.com/

Radiofrequency ablation involves the accurate placment of a very thin probe that looks like a hollow needle into the area of the nerve to be treated. Placement of the probe is verified by ultrasound or fluoroscopic guidance. A very mild current is then generated and the nerve stimulated twice. The first type of stimulation is sensory stimulation in which the patient will note a recreation of the type of symptoms experienced. The second type of stimulation is motor stimulation which a lower frequency current is applied which activates the one motor branch of Baxter's nerve, the nerve to the fifth toe. One can observe the 5th toe gently move or flex. So there is triple verification of accurate placement of the probe: imaging (ultrasound or fluorscope), sensory stimulation and motor stimulation. Next the radiofreqency current is activated an the nerve heated to about 80 degrees C or 170 degrees F for a little over a minute, just enough to deactivate the sensitive pain fibers.

Relief is often immediate and the patient leaves the office or outpatient surgicenter with a bandaid and standard shoegear. Unlike chemical neurolysis, radiofrequency ablation only need be applied in one treatment.

https://www.heelpain.pro/

https://www.southtexaspodiatrist.com/


Heel pain - getting the proper diagnosis

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I see many patients with heel pain in my practice as a San Antonio podiatrist, who have had the problem for months, if not years but have never had a well defined treatment plan.
Such treatment plan starts with an accurate diagnosis. Plantar fasciitis, inflammation of the ligament which supports that arch and originates on the heel bone is the most common cause of heel pain.  Other causes may include:...stress fractures of the heel bone (calcaneus), Baxter's neuritis - a nerve entrapment of a small nerve branch beneath the heel bone, plantar fasciosis - degenerative process of the plantar fascia, rheumatologic entities such as Reiter's syndrome, rheumatoid arthritis, gout, psoriatic arthritis, irritable bowel syndrome, ankylosing spondylitis; chronic pain syndrome due to overuse of steroids (cortisone shots), plantar fascial tears, plantar fibromatosis, infections, tumors, cysts....Ed Davis, DPM, FACFAS https://www.southexaspodiatrist.com/