Current Insights On Conservative Care For Heel Pain

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A Few Thoughts On Calcaneal Apophysitis

Heel pain in children is commonly caused by calcaneal apophysitis or Sever’s disease. This is a traction apophysitis at the calcaneus due to the pull of the Achilles tendon insertion and the origin of the plantar fascia. Typically, the child is involved in a youth sport or activity, such as soccer, baseball, track or basketball, which involves a lot of running and jumping.

   Usually, the condition will resolve on its own over time but it is helpful to treat symptoms in the active child using many of the aforementioned treatments such as taping, proper shoe recommendations, ice, stretching (not during acute episodes), etc. I like to apply a low Dye strapping with a closed basket weave on the heel. This has worked very well in allowing children to participate in their activity relatively pain free.

   Institute a stretching exercise program for the Achilles tendon and plantar fascia when the child is not in a pain cycle. Addressing footgear is also critical in allowing the child to return to activity and reduce symptoms.

   During the exam, the child with calcaneal apophysitis will have a positive squeeze test with medial and lateral compression over the heel with localized tenderness. The activity level is based on response to treatment and minimizing pain with activity.

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Author(s): 
Tim Dutra, DPM, MS

Emphasizing the importance of addressing the cause as well as the symptoms of heel pain, this author shares tips and pearls from his clinical experience on conservative modalities ranging from corticosteroid injections and taping to physical therapy and night splints.

Treating heel pain can be a real challenge. It is very important to get a detailed history from the patient as to the etiology of the heel pain. The vast majority of heel pain results from overuse. When acute injuries become chronic, one should identify and address biomechanical causes. Evaluating the patient’s training, shoe gear and any previous treatment is essential to a successful treatment plan.

   Commonly, the diagnosis points to plantar fasciitis. However, remember there are many causes of heel pain and your differential diagnosis could include a calcaneal stress fracture, nerve entrapment/neuritis, calcaneal apophysitis, calcaneal bone cyst, Reiter’s syndrome or a possible tumor. A good history and exam will help pinpoint a diagnosis and direct a subsequent treatment plan.

   Heel pain in the athlete is commonly caused by an increase in the intensity and frequency of activity. Often the athlete is adding running to the workout routine and for cross-training workouts. A good history will include the following key points: sudden or gradual onset of pain, localized or diffuse pain, pain intensity (scale of 1-10), duration of pain and what relieves the pain. The patient history also includes any prior history of problems, any previous treatment, any changes in training intensity and frequency, and any changes in athletic footwear.

   The problem with using the pain scale is getting the patient to understand the relative number as most patients will say it is a 10. It is sometimes difficult to determine if the pain is mechanical or neurological in nature. Commonly, the pain is insidious in nature and there is no incidence of trauma.

A Two-Pronged Approach To Treatment

To develop an effective treatment plan, one should consider using what I refer to as a “two pronged” treatment approach for the patient. This approach considers treating the symptoms and treating the cause. Treating the symptoms of pain and inflammation would include any combination of: nonsteroidal anti-inflammatory drugs (NSAIDs); cortisone injection; physical therapy; or cryotherapy. Treating the cause would include any combination of: taping; orthotics; shoe recommendations or modifications; night splints; cross training; and/or modification or restriction of activity.

   Too often, a treatment plan will address only one of these areas. For example, the patient receives an injection, which does nothing to address the cause of the heel pain.

   I have found taping to be a valuable tool in treating heel pain but it appears to be a lost art. Taping can be therapeutic as well as diagnostic in determining if a patient could benefit from functional orthotics. I like to say, “Orthotics are only as good as the shoes that you put them in.” If shoes are worn out or not recommended for your patient, orthotics will not be as effective in controlling the foot.

   The biomechanical exam and gait evaluation are critical to addressing the underlying cause. You need to determine what diagnostic studies are needed to confirm your diagnosis, especially if it does not appear to be your classic plantar fasciitis injury.

Is Stretching Beneficial For Patients With Heel Pain?

To stretch or not to stretch — that is the question. All too often we will recommend stretching to patients for treating heel pain in the acute phase of the injury. Unfortunately, stretching often starts before the area has healed sufficiently. Stretching should not begin until the rehabilitation phase of the injury, after the healing phase has occurred. If stretching starts too early, it creates a vicious cycle and can prolong the healing of the injury.

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Anonymoussays: November 8, 2010 at 6:44 am

All interested might want to check out a systematic review by van de Water et al. (published earlier this year) about the effects of taping on plantar fasciosis.

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