Case Studies In Cryosurgery For Heel Pain

Author(s): 
By Marc Katz, DPM

Cryosurgery is an effective pain relief modality that uses freezing temperatures for ablation of the nerves that provide sensation to the heel. While this treatment is relatively new for foot pain, physicians have utilized cryosurgery for pain relief for decades. This modality has proven to be a viable treatment and is an excellent choice for appropriate patients prior to considering more invasive procedures.

Heel pain has become an epidemic in our society. Diabetes, arthritis, weight gain, injuries, previous heel surgery and other medical conditions are known contributing factors. There is also a psychosocial aspect that one must recognize when treating the heel pain patient. When people live with pain on a daily basis, they have difficulty performing simple daily activities. Some have difficulty sleeping or simply walking. This often leads to depression, weight gain and stress. The cycle continues, leading to further distress and life changes that are difficult.

In addition, patients are unable to remain off from their jobs for long periods of time and are often involved in jobs that require standing and walking. Additionally, active patients are eager to return to exercise and activities.

In many cases, physicians can help facilitate heel pain relief with conservative therapy options including: orthoses, physical therapy, strapping/padding, night splints, stretching, cortisone injections and antiinflammatory medications.

When Conservative Therapy Fails
When a patient with heel pain does not respond to conservative or surgical therapy, the physician must reevaluate the patient and look for other causes of pain. Unfortunately, physicians often do not explore a diagnosis beyond plantar fasciitis. When conservative therapy fails, physicians often proceed to a fasciotomy.

It would be beneficial for the clinician to consider other etiologies prior to surgery. Patients who get no relief from plantar fasciotomy have often been misdiagnosed.

In addition, poor surgical incision planning for plantar fasciotomy and endoscopic procedures will often lead to a neuroma of the medial and sometimes the lateral calcaneal nerve branches. These scenarios are often written off as a failed surgery without taking the time to diagnose other causes of pain.

Where Does Cryosurgery Fit Into The Armamentarium For Heel Pain?
Cryosurgery, while relatively new in the podiatric community, is by no means in its infancy or experimental. Pain management specialists typically use the procedure for peripheral nerve pain throughout the body.1 Cryosurgery is a procedure that involves freezing the abnormal sensory nerves to relieve pain. In my opinion, one should consider cryosurgery prior to other surgeries because it is minimally invasive, quick healing and provides superior results with fewer complications.

Podiatry has the unique opportunity to embrace this technology and improve techniques through more widespread use. We are the experts in heel pain relief and should move to the forefront whenever technology is present and available. While not all podiatrists need cryosurgical skills, the podiatric community should look to qualified colleagues who have these skills and maintain a referral relationship to help patients with recalcitrant heel pain.

Indications for cryosurgery include pain relief from heel pathology. Heel pain often is a result of mechanical foot problems in combination with injury to the medial and lateral calcaneal nerves. Another possible cause is nerve entrapment. This occurs with supination and compression of the lateral calcaneal nerve, a branch of the sural nerve. Painful heel neuroma formation from poorly planned incision sites and pain secondary to syndromes, such as cuboid syndrome following fasciotomy, are other possible indications for cryosurgery.

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