Dr. Ed Davis, San Antonio Podiatrist - Heel Pain

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 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)

 

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.

 

 

For more information visit:  Podiatrist San Antonio

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

Definitive treatment for heel pain in teens is available at the office of San Antonio Podiatrist, Dr. Ed Davis

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

Related articles

Orthotics to Correct Calcaneal Inversion Running

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.   We use the Swiss Dolorclast made by EMS, the Storz/Curamedix  Orthopulse  and the Storz/Curamedix Intellect FS-W focused ESWT units in our office.  

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

https://www.southtexaspodiatrist.com/

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