Reconsider Biomechanical Causes In Heel Pain Cases

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Key Differentials To Consider In Your Examination

When attempting to make a diagnosis of heel pain, there are a number of well-known differentials you should consider. These include apophysitis in children, fracture or trauma to the heel, and systemic illnesses such as rheumatoid arthritis, Reiter’s disease and ankylosing spondylitis.

The literature reports other causes as well. One that has recently gained more attention is nerve entrapment either within the tarsal canal or along the medial calcaneal branch of the medial plantar nerve. Consistent with this process is a triad of symptoms that have been reported together as well. These include posterior tibial tendon dysfunction and plantar fasciitis leading to a traction injury on the tibial nerve producing tarsal tunnel syndrome.

Whatever the cause of heel pain may be, starting off with a complete history and examination is essential in making the proper diagnosis. In addition, lab work and X-rays are often warranted in aiding the diagnostic process. The patient history often provides an abundance of information that you’ll need to sort through for important clues.

The shoes patients wear are often a key source of information. They say a lot about patients without you even asking a question. In fact, you can immediately obtain information as soon as you walk in the room with a quick glance at what they are wearing. Along this line are related questions about their footwear, what they most commonly wear and whether they go without shoes when they get the chance. Sometimes this may enable you to stumble over a simple change to their lifestyle that may aid in alleviating the heel pain.

Obviously, the easy patients are those who respond quickly to the initial line of therapy and advice. However, the more chronic the heel pain, the more thorough your examination needs to be. The patients with the chronic heel pain are the tough ones. They are the ones who take more time and energy to figure out. After all, the chronic heel pain patients have to overcome two things — the inflammation and the biomechanical etiology that caused the pain to occur.

The ink mat is a valuable screening tool that is fast and easy to use. It is also a great tool for patient education.
Shoe fit is critical for optimal foot function. The ball of the foot should be at the proper place inside the shoe. If it is not (as seen above), the foot and the shoe will not work together. The break point in this photo is too far forward, forcing the s
There are many ways to obtain a cast impression of the foot. Determining the best method will depend on the mechanics of the foot as well as what you want the shoe to achieve.
This rocker sole is one of many different types of shoe modifications that you can use to improve foot function. Rocker soles can have several different variations, depending on what you are trying to achieve in a particular situation.
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Author(s): 
By David Levine, DPM, CPed

Some days, it seems to be an epidemic. As you read the patient information sheet prior to entering the examination room to meet a patient for the first time, you start to wonder if everyone will eventually wind up with heel pain at some point in their lives. Sometimes it is easy to see why a person might be suffering with heel pain. Obesity, poor shoe selection and a job that requires extensive standing or walking are obvious contributing factors.
In other situations, the cause(s) might be more perplexing. For instance, when a patient who has already received orthotic devices or even one who has previously had surgery for plantar fasciitis presents with heel pain, it may be more difficult to pinpoint the cause of the pain.
Keeping to a schedule with a waiting room full of patients can make it very difficult to unmask the true etiological factors causing heel pain. Many only consider the simple approach of injecting, administering NSAIDs and stretching prior to recommending surgery. However, delving into the biomechanical issues might lead to even better outcomes and more satisfied patients, and may open your eyes to how other biomechanical conditions may contribute to the problem.
What about chronic heel pain patients? These people may have been to their primary care physicians or orthopedic surgeons, received three injections and NSAIDs, and are still enduring pain after three months or more. Indeed, when we are treating this population of patients, we should pay particularly close attention to biomechanical considerations.

Key Pointers For Assessing Footwear
This starts with the footwear. Look at the type of shoe the patient wears. Simply hold it in your hand and determine whether it meets the following simple criteria.
1. Does the shoe fit? Assessing the insole by looking at the toe print will give you an idea if there is enough room in the shoe for the patient’s foot to spread out and function properly. Also, this may allow you to see if the ball of the foot is located at the proper place.
2. Where is the break point of the shoe? When flexing the shoe, it should bend at the ball of the foot. There are many shoes that flex in the arch. The foot doesn’t bend there so why should the shoe? You want the shoe to work with the foot, not against it.

3. Is the construction of the shoe appropriate for the foot type? For instance, in a foot that has a highly inverted heel strike (i.e. tibial varum), is the upper of the shoe strong enough to remain over the sole? If it isn’t, it will breakdown laterally, forcing the foot to land in an even more inverted position, which will subsequently lead to even more pronation than what the foot would normally do. The opposite can be true as well. With a pronated position to heel strike, the shoe will break down medially and the foot will hang over the sole, leaving inadequate support for the foot and the likelihood of continued strain on the plantar fascia.
4. Is the shoe appropriate? Many people will choose to get shoes by looks or what is on sale. That may work for many people, but once a foot problem develops, the shoe takes on a different meaning. It transforms from something to wear to a medical device.
Evaluating the entire person who fits into the shoes will improve your outcome. Even though it may be just the heel that is hurting, looking at the entire person is important. Heel pain may only be a manifestation of more proximal biomechanical imbalances. Going into every iteration of biomechanical possibilities is impossible, but there are some key considerations that warrant a closer look.

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