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

Can Physical Therapy Have An Impact?

Physical therapy can be beneficial in the treatment process and the earlier it begins, the better. There are many modalities that one can prescribe such as icing, massage, ultrasound, iontophoresis, stretching and strengthening exercises.

   Remember that physical therapy is a prescription so you need to order the frequency and duration of therapy, and establish specific goals. Physical therapy needs to be at least two to three times per week to be effective. I will usually reassess the patient at three- to four-week intervals. If physical therapy is not helping patients after several weeks, reassess the plan. If patients are progressing well, I will often continue their therapy.

   The major goals of physical therapy are to decrease pain and increase function. Patients need to understand treatment expectations. I also like to make sure patients receive home exercises to do so they take an active role in their treatment. It is important to work closely with a physical therapist and athletic trainer in the treatment of heel pain.

What You Should Know About Taping

Taping should be the key ingredient in treating heel pain that is mechanical in nature. As I said earlier, taping is becoming a lost art but it is therapeutic as well as diagnostic. When one properly applies a low Dye strapping, it can provide dramatic relief of symptoms. Physicians can apply this strapping with accommodative padding, such as a cobra pad or medial longitudinal arch pad. I will typically offer taping to all of my heel pain patients who have a biomechanical cause of the pain, which one typically sees with plantar fasciitis. I always check to make sure the patient has not had any trouble with taping in the past.

   I use a pre-tape spray. Using 1-inch anchors and 2-inch strips, I apply the strips in an overlapping fashion from lateral to medial, causing an anti-pronation force. I will apply another anchor and then repeat another series of overlapping straps. Then I apply a retention strap on the dorsum of the foot to secure the tape job.

   Ideally, the tape job can last several days. Sometimes I will do a criss-cross strapping under the arch if the patient has a cavus foot type and that will tend to provide better support. Although the tape will stretch some in a short time, the proprioceptive feedback benefit will last much longer.

   I allow the patient to take a brief shower and then use a hair dryer to help dry out the tape job. Since I use porous cloth athletic tape, it holds up pretty well for several days to a week if needed. If you are taping the patient multiple times for several weeks, an under-wrap or pre-wrap will help protect the skin.

   Taping restricts excessive motion but allows for functional movement. Taping is not a substitute for rehabilitation but rather an adjunct therapy. If patients respond well to taping, it is a good indication that functional orthotics will be a benefit for them. Usually, if the patient does not respond to a low Dye strapping, the problem is most likely not plantar fasciitis.

What About Functional Orthoses And Night Splints?

Functional orthotics can greatly benefit patients who have had heel pain and chronic plantar fasciitis. Typically, I will put them in a flexible orthotic with a deep heel cup, wide plate and rearfoot post. A medial heel skive of 2 to 4 mm is also helpful in patients with extreme pronation. A plantar fascial groove may be needed for patients who have a tight plantar fascia to prevent irritation of the medial arch. The easiest way to check is to maximally pronate the foot and dorsiflex the hallux as a tight medial band will be prominent. Sometimes one can use a cobra pad to help increase the medial arch height and decrease pronatory forces. A prefabricated sports orthotic can also be helpful in the interim but usually the patient will require a prescription custom orthotic because of the benefits of a heel cup and rearfoot posting providing more support. I typically do not use orthotics in acute or sub-acute cases, or with patients who have not postively responded to taping.

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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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