Children may develop pain often associated with running or sports between the ages of 8 to 14. This is called Sever's disease or calcaneal appophysitis and is discussed in the common foot problem section. This condition usually responds very well to foot orthotic therapy and allows children to get back to their sports right away.
Adult Heel Pain
Adult heel pain is one of the most common problems seen in podiatry offices. The pain can com from a number of conditions. The most common are plantar fasciitis-fasciosis which is seen as pain along the bottom of the heel, those pains due to nerve injury or entrapment (such as tarsal tunnel syndrome, and lastly pain in the back of the heel.
Plantar Fasciitis or Fasciosis
Pain in the bottom of the heel is most often caused by inflammation or disease of the plantar fascial ligament, referred to as plantar fasciitis or plantar fasciosis. The plantar fascia is a heavy-duty ligament which runs from the bottom of the heel and fans out to Insert into the bases of the toes at the ball of the foot. Plantar fasciitis refers to inflammation of the ligament in it's earlier stages. Plantar fasciosis refers to degeneration of the fascia in it's later, more chronic states. When people bear weight, excess stress is placed on the ligament which shows up as pain, usually at the insertion into the heel bone. This can affect many different groups from competitive athletes to sedentary people. It becomes more common with overweight persons or those with tight Achilles tendons. It can affect persons with flat feet (which cause stretching of the ligament) or high arches (often have a higher impact in gait). Heel spurs may be present, however, these are usually not felt to be the actual cause of the pain, but rather a finding on the X-ray that is often seen associated with the inflamed ligament.
Ultrasound Image of the Bottom of the Heels
The image is upside down because the side where the probe is held is always up. The white lines are the bottom of the heel bones. The plantar fascia ligaments are coming in from the left side. Notice how much thicker the ligament is on the right side (7.6mm) where it attaches to the heel bone, versus the left side (3.6mm). The increase in thickness is proportional to the amount of inflammation. It is also darker - this is because fluid is darker and there is more fluid with swelling (edema).
Nerve Injuries as a Cause of Heel Pain
Heel pain can also results when the posterior tibial nerve or it's branches to the heel become injured or entrapped with tight ligaments or scar tissue. This may be referred to as tarsal tunnel syndrome, which is similar to the carpal tunnel syndrome found in the wrist. This may be aggravated by people who pronated (arches flatten) excessively. Foot orthotics, injections, cryosurgery or open surgery may be used to relieve these conditions.
Pain in the Back of the Heel
Pain in the back of heel may be cause by a bone projection or spur, or by inflammation of the Achilles tendon when it inserts into the back of the heel bone. X-rays or an imaging ultrasound examination are necessary to diagnose these conditions.
Depending on the condition and severity, foot orthotics, injections, cryosurgery, casts or open surgery may be necessary.
The Initial Examination and Treatment:
When patients present with heel pain it is common to perform an imaging ultrasound examination to determine if the ligament is swollen. Treatment for plantar fasciitis-fasciosis is initial conservative and is usually successful 90% of the time. Initial treatment may include taping, cortisone injection, foot orthotics (custom molded inserts), stretching exercises. We are usually able to give relief to your heel pain on the initial visit.
Should someone not respond to these treatments, then Cryosurgery (cryoanalgesia) should be considered. This is a minimally invasive procedure, done under local anesthesia that takes about 7 minutes to perform. A very small probe is used to freeze the ligament and nerves to eliminate the pain. No stitches are necessary. Afterwards patients put there shoes on and return to near-normal activities (we recommend avoiding strenuous exercise for a few days).
Extracorporeal Shock Wave Therapy can also be effective. This is when intense sound waves are directed into the fascial ligament where it inserts into the heel. This is done under local anesthesia and you are able to walk immediately. For more information, go to http://www.curamedix.com.
Rarely, there will be some that do not respond to conservative treatments and will require surgery by releasing the plantar fascia ligament or removing a heel spur if present. While this is by far the exception, it should be noted that no treatment works 100% of the time.
We are proud to be able to off a number of treatment options to relieve heel pain:
CRYOSURGERY is a new options that offers quick relief of heel pain with minimal risk. We are proud to be the first office in San Diego County to be certified in cryosurgery of the foot. This is a minimally invasive procedure done in the office under local anesthesia. It only takes a few minutes and the patient is able to walk immediately.
MLS Laser Therapy - offers a non-invasive treatment for musculoskeletal pain, including plantar fasciitis. This is a painless procedure, done in the office and not requiring anesthesia. For more information, go to our section on MLS Laser Therapy.
FOOT ORTHOTICS are a very good, conservative options with a high success rate. Foot orthotics are custom-molded supports that control the way the foot functions, similar to the way glasses control the way the eyes function to allow the user to see better. Foot orthotics decrease stress to the painful area of the foot.
We maintain our own in-office computerized orthotic laboratory to allow rapid fabrication of quality orthotics. Orthotics may be made for any type of shoe: athletic, dress, heels, sandals.
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