Dr. Ed Davis, San Antonio Podiatrist - Heel Pain Blog

Regenerative Medicine and Heel Pain, Part 2 - Dr. Ed Davis, San Antonio Podiatrist, discusses advanced treatments for heel pain.

Growth factors from stem cells can help heal damaged tissue

Heel Pain Blog

Plantar fasciitis is an inflammatory condition of the fascia.   If plantar fasciitis persists, chronic inflammation can lead to long term degenerative changes of the fascia known as plantar fasciosis.   The fascia, in plantar fasciosis can become thick and relatively hardened with loss of normal flexibility.    The plantar fascia is a broad band of fascial tissue that spans the foot from the heel to the ball of the foot.  It acts both to support the foot and function as a spring to aid in propulsion.

The plantar fascia, like most fascia in the body has little or no blood supply of its own but derives that supply from surrounding muscle tissue.  As the fascia thickens due to chronic inflammation, it becomes more difficult for blood to perfuse it so the center of the fascia, the area furthest away from the blood vessels becomes diseased.

Not all longstanding or seemingly difficult cases of heel pain are due to plantar fasciosis.   The best way to determine if fasciosis is present is via imaging, specifically diagnostic ultrasound (sonography) which is the gold standard for analysis of such tissue due to its ability to show fine details.

The goal of treatment of fasciosis involves the induction or stimulation of the process of tissue repair, that is, getting the body to remove the diseased tissue and replace it with normal tissue.  That is the basis of regenerative medicine. 

The first form of regenerative medicine for fasciosis was ESWT or extracorporeal shockwave therapy.  ESWT involves the application of sonic shockwaves, similar to the technology used to break down kidney stones, to induce regeneration of the fascia.  ESWT induces neovascularization, the production of new blood vessels and effectively thins the fascia making it more flexible, more functional and less painful.  The process takes approximately 12 weeks but patients generally experience relief starting about the sixth week after treatment.

Tissue regeneration can also be encouraged by the introduction of growth factors into the fascia.  Growth factors are proteins that signal tissue repair.  That occurs by stimulating cell growth, cell differentiation (formation of different types of cells) and tissue repair.   Tissue repair involves removal of diseased tissue and its replacement with healthy tissue.  We generally explain that ESWT is a two part process:  stimulation of breakdown of bad tissue followed by creation of good tissue although the processes can occur simultaneously.  The addition of growth factors can accelerate the second half: tissue regeneration.

One of the earlier means of providing growth factors was by use of PRP or platelet rich plasma.  The involves drawing blood and removing the portion of plasma that contain platelets.  Platelets are involved in the clotting mechanism but also are a source of growth factors.  Stem cells are the most concentrated source of growth factors although the process of extracting stem cells is a bit involved and expensive.  Growth factors of stem cell origin can be obtained from other sources.  There have been ethical questions with respect to embryonic stem cells but not so for amniotic stem cells.  Amniotic stem cells are present in amniotic fluid and amniotic membrane.

Amniotic stem cells contain naturally occurring anti-inflammatory agents such as cytokines as well as growth factors which stimulate tissue growth.  Amniotic fluid is a very concentrated sources of stem cells so its use is more practical than trying to extract stem cells from a patient’s own bone marrow or fat cells.   Amniotic fluid is “immune privilege” which means that rejection of the fluid is rare.  The use of the amniotic stem cells source safe,  effective and well researched.  The end product used has few stem cells but retains the necessary growth factors. All amniotic stem cell donors go through a rigorous screening process, as determined by the Food and Drug Administration (FDA) and American Association of Tissue Banks (AATB).

 

Heel Pain Blog 

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.  Excess twisting of the fascia causes heel pain due to plantar fasciitis.

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 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.

San Antonio Podiatrist, Dr. Ed Davis utilizes the latest regenerative medicine techniques

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.

52. 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.
53. Eming SA, Krieg T, Davidson JM. Inflammation in wound repair: molecular and cellular mechanisms. J Invest Dermatol. 2007;127:514–525.
54. 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.
55. 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.
56. 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.

15. 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.

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.

via sanantoniopodiatrist.typepad.com

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

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:  http://www.heelpain.guru.  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: http://www.podiatrytoday.com/article/6294     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  http://www.southtexaspodiatrist.com/

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

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   http://www.southtexaspodiatrist.com/

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, originating 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 $25 to $75 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: http://www.footorthotics.pro

 

Podiatrist San Antonio discusses alternate causes of heel pain

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

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.  With the advent of ESWT, surgical treatment of plantar fasciosis is rarely required.

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

 

Baxter's neuritis, a common cause of heel pain

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: Abbott radiofrequency ablation

Radiofrequency ablation involves the accurate placement 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 radiofrequency 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 often occurs within a few weeks and the patient leaves the office  with a bandaid and standard shoegear. Unlike chemical neurolysis, radiofrequency ablation only need be applied in one treatment.

 

https://www.southtexaspodiatrist.com/

Advanced treatments for plantar fasciitis.

Four advanced treatments for "difficult" cases of plantar fasciitis or plantar fasciosis are offered by San Antonio Podiatrist, Dr. Ed Davis.

1) The Topaz Procedure:  This procedure is a minimally invasive procedure for plantar fasciitis that involves use of a small wand made by Arthrocare.  It employs radiofrequency utilized by the surgeon to debride or thin the fascia at the heel, that is, remove the diseased tissue causing the heel pain.  The procedure is performed via tiny "puncture" holes made in the skin at the bottom of the heel that require no sutures and leave no scarring.  Patients can walk on the area the next day.  http://www.topazprocedure.com/

2) ESWT or extracorporeal shockwave therapy:  This procedure is a non-invasive and involves the use of a machine that generates sonic pressure waves to induce remodeling or repair of the diseased fascial tissue at the heel.  It is also effective for achilles tendon problems.  The procedure is performed in the office without the need for anesthesia and patients can return to activity the same day.  Dr. Davis owns and uses three different ESWT technologies to obtain optimal results.  The Swiss Dolorclast which is a third generation ESWT machine manufactured by EMS:  https://www.ems-dolorclast.com/products/swiss-dolorclastr-classic

Radial ESWT

 

The Storz/Curamedix Orthopulse provides exceptional technology and versatility to ESWT treatments.

Focused ESWT can provide more targeted treatment and has demonstrated significant effectiveness in the promotion of regeneration of damaged fascia and tendons.  We use the Storz/Curamedix Intelect FS-W focused unit in our office.

Focused ESWT

 

3) MLS Laser Therapy:  MLS laser is a modality in which is supplied by Cutting Edge Lasers, https://celasers.com/medical/.    The laser works by employing two synchronized wavelengths of light which treat damaged tissue at the cellular level to stimulate healing, reduce inflammation and pain.  I was introduced to this modality about a year ago but had difficulty understanding and accepting the concept behind this.  CE Lasers initially sold to the veterinary market in the US despite fairly widespread use of the products in Europe.  There is no placebo effect with animals.  I talked to several veterinarians using the CE Laser before becoming convinced of its efficacy.

 

4) Platelet rich plasma (PRP):   Platelet rich plasma has become a popular and somewhat glamorous new treatment modality used by professional athletes for injuries. PRP is a concentrate of whole blood of the patient in which the the platelets are concentrated in a small portion.  The platelet concentrate is then reinjected into the injured area.  Platelets are involved in the clotting mechanism so bruising and swelling can be decreased.  Platelets contain growth factors so, in concentrated form, the amount of growth factors can be increased in an injured area.  Results in the press and literature have been mixed but there is a reason for this in my opinion.  PRP is often used as a primary treatment or sole treatment. There may be a benefit to do so but the underlying cause of tendon and ligament pathologies must first be addressed otherwise lasting relief may not occur.  I use PRP as an adjunctive treatment; for example, I will inject PRP into the plantar fascia after performing the Topaz procedure.  I use the same strategy with the CE Laser, utilizing it in conjunction with ESWT.

5) Amniotic membrane injections:  There is a lot of discussion about the use of stem cells to aid in the regeneration and repair of damaged tissues.  Use of actual stem cells involves a minor surgical procedure to extract the cells and, as such, is not commonly performed.  Stem cells contain growth factors and the primary goal is to be able to use the growth factors.  PRP contains growth factors but at a lower concentration than growth factors derived from tissues with high concentrations of stem cells.   A common source is amniotic fluid.  A number of companies harvest donated amniotic fluid to prepare injections rich in growth factors.

For more information see our heel pain website:  http://www.heelpain.pro/

Treatment Triad for Plantar Fasciitis

Treatment Triad

I coined the term "treatment triad" for plantar fasciitis a few years back to better describe the disease process and its treatment. 

Acute plantar fasciitis is basically a sprain of the fascia, it is an inflammatory condition. It thus can be treated successfully with anti-inflammatories -- oral or injections or cortisone plus the use of soft heel pads or OTC inserts (acute PF can sometimes progress to chronic PF but lets leave that out for simplicity's sake for now).

Plantar fasciitis that persists or becomes chronic does so for one of two reasons....
...abnormal or excessive strain persists on the fascia. This may be due to work conditions, poor shoegear, poor body mechanics: subtalar joint overpronation, midtarsal joint oversupination, tight achille-gastrosoleus.

...tissue quality deteriorates. This can occur due to chronic inflammation which leads to tissue damage, genetic factors leading to poor connective tissue quality or a combination of both.

LEG #1 = inflammation, 

LEG #2 = abnormal biomechanics, 

LEG #3 = poor tissue quality(degeneration of the tissue due to long term chronic inflammation)

The 3 "legs" of the triad thus have different "height" at different times.

Initially the first leg, "inflammation" is by far the predominant process. As such expect modalities such as cortisone shots to work reasonably well in the first few weeks or few months, then gradually decrease in effectiveness with time. As time goes on and if plantar fasciitis persists, the second leg must be focused on. The body can and does repair itself and if that is not happening then one must remove impediments, ie. find and remove the biomechanical problems preventing that from occurring. Look carefully at the second leg from 6 weeks to 6 months. Inflammation and tissue damage occurring for extended periods of time (say greater than 6 months) will compromise the body's ability to repair tissue. The tissue becomes badly scarred and devascularized. This is the point where the third leg predominates -- tissue quality.

Problematic biomechanics is best treated by a practitioner trained in that area.  There are many who dabble in the area of biomechanics, from shoe fitters to retail stores, etc.  Expertise in biomechanics is derived from years of study. Biomechanical issues are addressed by changes in shoegear, prescription foot orthotics, manual therapy/physical therapy.  Dr. Ed Davis explains how foot orthotics can be effective:  https://www.footorthotics.pro/

 

How is the third leg treated. The term "plantar fasciosis" is a relatively new term that specifically defines this degneration of the fascia. Such degeneration can easily be diagnosed by use of diagnostic ultrasound or sonography. It is important that the presence or absence of fasciosis be established early on so that treatment can be adequately targeted.  Surgical release of the plantar fascia was used at this stage but carries a potentially long recovery period as well as what I would consider an unacceptably high complication rate. It has been supplanted by less invasive, safer and more effective treatments to include ESWT (extracorporeal shockwave therapy) and more recently, the Topaz procedure, http://www.topazprocedure.com/, which is also known as a partial fasciectomy via coblation.  Coblation is a term meaning "cold ablation" and is a trademark of the Arthrocare Corp.

Now, one caveat, plantar fasciitis often waxes and wanes in the early stages for a number of patients so the "stages"  or "legs" I am discussing be affixed to firm time periods. For example, a patient can low grade chronic plantar fasciitis for years, change jobs to one that requires more standing and develops a bout of acute plantar fasciitis superimposed on the chronic process.

Heel Pain - Getting The Proper Diagnosis

The first step in treating heel pain is finding out the cause of the problem.

We see many patients with heel pain in our  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.   Plantar fasciitis can be caused by overuse and be transient but can often become chronic if the underlying causes are not identified and resolved. The plantar fascia is the large ligament that supports the arch and structures that support the foot.  It is strong but can be damaged over time.  The fascia has terrific tensile strength or pulling strength but is not strong when twisted. Twisting or torsional strain of the fascia occurs when overly soft shoes without support are worn or if the patient has biomechanical problems.  Overpronation, the foot rolling in too much or oversupination, the foot rolling out too much can strain the fascia causing it to become thickened and painful. The plantar fascia is not visible on x-ray so the most important first step is to obtain an ultrasound exam in the office to determine it's condition.

Treatments for chronic plantar fascia that are aimed at the cause may include use of more stable shoes (shoes with a shank), orthotics and physical therapy.  OTC orthotics or store purchase orthotics are primarily arch supports and lack the features of prescription orthotics but can be tried first.  For more information on orthotics please visit:  https://www.footorthotics.pro/

Occasionally, the fascia can thicken over time to where is is more difficult to treat and has been called "intractable plantar fasciitis."  The actual name for that condition is plantar fasciosis, which is a degenerative condition of the fascia.  That is readily identified by an ultrasound exam.  Plantar fasciosis includes a separate and distinct set of treatments from plantar fasciits.  Treatments for plantar fasciosis may include extracorporeal shockwave therapy (ESWT) and the Topaz Procedure:  https://sanantoniopodiatrist.typepad.com/my-blog/2013/05/eswt-or-extracorporeal-shockwave-therapy-for-the-treatment-of-heel-pain.html  and   https://www.topazprocedure.com/

Other causes may include:..

Stress fractures of the heel bone (calcaneus): https://sanantoniopodiatrist.typepad.com/my-blog/2015/10/stress-fractures-of-the-calcaneus-heel-bone.html 

Baxter's neuritis - a nerve entrapment of a small nerve branch beneath the heel bone: https://sanantoniopodiatrist.typepad.com/my-blog/2012/04/baxters-neuritis-a-common-cause-of-heel-pain.html

Rrheumatologic 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/