Thursday, September 24, 2009

Heel pain among kids

Heel pain among kids
I had a friend ask me yesterday about heel pain in her 11 year old son. He plays football, and has had pain for the last few weeks. It is becoming more severe, and is affecting his ability to play sports. Her question was what could be causing his pain, and if she should take him to the doctor for treatment. Obviously, it is not always possible to make a diagnosis without seeing the patient. In this case, though, in the absence of an injury, a diagnosis of Sever's disease (or calcaneal apophysitis) is the most likely cause of his symptoms.

Unlike classic plantar fasciitis, this condition occurs in the growth plate in the back of the calcaneus, or heel bone in pre-teen kids. It is most common in those who are very active in sports, and boys are affected more often than girls. Those who are overweight are also more prone to develop this condition.

Treatment consists of decreasing the inflammation in the area by the use of ice and anti-inflammatory medications. Also helpful is the use of a heel lift in the shoe. By raising the heel 1/4" to 3/8", the forces exerted on the growth plate by the achilles tendon are decreased. Stretching of the achilles tendon is also helpful. Finally, decreasing athletic activities is often needed to help resolve the symptoms. In the long run, this is a problem that will go away once the growth plate closes as the bone reaches maturity. For most children, this is at about at age 16. However, in the short term, treatment is important in order to allow patients to return to their preferred activities as soon as possible. Following resolution of the problem, prevention is important to avoid recurrence of symptoms. This includes the continued use of a heel lift. In some instances, taping of the foot or the fabrication of functional foot orthotics (see will help prevent the return of this painful condition.

Wednesday, May 27, 2009

Orthotics as a treatment for heel pain (plantar fasciitis)

In my opinion, treatment for plantar fasciitis almost always includes the dispensing of functional foot orthotics. The cause of plantar fasciitis is the overstretching of the plantar fascia which leads to inflammation and pain. Orthotics are useful in that they help to relieve excessive stretching of the plantar fascia, and thereby can not only be used to treat the symptoms of heel pain, but also help to eliminate what is causing the problem.

Orthotics are often confused with arch supports, but there are significant differences. Although they may look similar, orthotics are custom made from an impression of the foot. There are a variety of ways to take the foot impression, including the use of plaster casting material, foam, and digital scanning. Each method has its advantages and disadvantages.

Plaster casting is the oldest method, and is still widely used today because it provides an excellent representation of the contours of the foot. It also has the advantage that if done properly, the foot can be held in a neutral position. What this means is the doctor has the ability to place your foot in the position that he or she would like it to function in while you're standing or walking. This, I believe, will give you the best chance of receiving orthotics that are comfortable to wear, and also be effective in relieving your symptoms. Plaster casting does take more time, and is messy, but I have found that it works best for me in my office.

Foam is also used to take foot impressions. Your foot is placed in the foam, and you end up with an instant impression of your foot without the mess of plaster. The disadvantage is that the doctor has much less control of the placement of your foot while the impression is being obtained, leading to less reliable orthotics.

Digital scanners are a relatively new method of obtaining a foot impression which allow the doctor to control the position of the foot during the procedure. It is fast, clean and easy to do. Once the image is obtained, it can be sent to the lab electronicaly to begin the process of fabrication immediately. This leads to you get your orthotics sooner. The downside to the use of optical scanners is the cost of the equipment, which has kept it from being implemented in more offices.

There is one final method that is used to obtain an impression of the foot that uses a pressure plate to estimate the contour of the foot. Using these devices is very quick, and like with the optical scanners, the order can be sent electronically to the lab. However, it is impossible for a pressure mat to get an exact contour of the foot, so in my opinion, orthotics made using this method of obtaining foot impressions lead to less than optimal orthotics. I do not consider such devices to be custom or functional.

Once you receive your orthotics from the lab, you may experience a period of time of adjustment to get used to wearing them. It is not uncommon for minor adjustments to be made. These can usually be made in the office. Most labs allow 90 days for adjustments to be made without additional charges, so if there is a problem with your orthotics, make sure you let your doctor aware of the problem within the first 90 days after receiving them.

Patients are sometimes surprised to learn the cost of functional foot orthotics. While they are expensive to make, most will last for years, and if the pain is resolved with the use of orthotics, I'm certain you will find that money was well spent.

Wednesday, May 6, 2009

Treatments for Plantar Fasciitis

Once a diagnosis of plantar fasciitis is made, treatment can begin immediately. For a patient seen in my office for the first time with this condition, one of the first treatments I offer is to apply strapping to the bottom of the foot. What this does is to help relieve tension on the plantar fascia. Once applied, many patients say they can tell an immediate difference in the level of pain that they are experiencing. Obviously, strapping the foot with tape is not a permanent treatment for this condition. What it does do, however, is provide temporally relief of symptoms. I have found that when patients obtain relief with foot strapping, that they will also find relief in most cases with functional foot orthotics. The strapping is usually left on the foot for two to three days, and during that time it needs to be kept dry. A plastic bag can be placed around the foot and ankle to keep it dry during bathing.

The use of anti inflammatory medication (such as aspirin, Motrin, etc.) is also useful in treating plantar fasciitis. While this does not treat the cause of the problem, it may help relieve the symptoms.

Over the counter cushioned arch supports may also be recommended to give support to the arch and cushioning to the heel. In some cases, this may be all that's needed to treat your heel pain. You should look for an arch support that will actually support your arch, and at the same time give adequate cushioning. I recommend Spenco® Polysorb® Walker/Runner Premium Insoles. They can be purchased at my office, and at many fine shoe stores. The advantage they have is that they tend to hold up well with use, and have a one-year unconditional guarantee. They are also accepted by the American Podiatric Medical Association.

For instant relief, I will offer patients samples of Biofreeze®, a topical pain reliever, which can help relieve the symptoms of plantar fasciitis. It is applied to the affected area of the foot multiple times a day, and I find that patients love it! You can read more about Biofreeze® on my Foot Product review blog at

Finally, Stretching of the plantar fascia is very helpful, especially in the morning when you get out of bed. This is done in a couple of ways. First, sit on the side of your bed and grab your foot. Then, pull your foot upwards, pulling the toes towards your knee. By stretching the plantar fascia, you may help reduce the pain you experience when you first get out of bed in the morning.

On subsequent visits, more definitive treatments are initiated. Taking impressions of the feet for functional foot orthotics almost always tops my list. On the next post, I'll discuss orthotics in more detail.

Monday, May 4, 2009

Diagnosing Plantar Fasciitis

By far the most common cause of heel pain is plantar fasciitis. This condition occurs when the major ligament on the bottom of the foot, the plantar fascia, becomes inflamed and painful. Usually, a person develops symptoms when he/she increases their activity level in some way over a short period of time. Wearing shoes with poor arch support, and walking on hard surfaces are also factors in developing plantar fasciitis.The pain from plantar fasciitis is normally localized on the bottom of the heel. Patients describe the pain as being moderate to severe in most cases. You'll find that if you have plantar fasciitis that the pain will most likely not be the same throughout the day. When I hear a patient say that their worst pain of the day is when the first get up out of bed in the morning, or upon standing after prolonged periods of sitting, I put plantar fasciitis on the top of my list for their cause of heel pain.The diagnosis is made from the patient's history, the examination, and usually x-rays. When a person has had plantar fasciitis for a long period of time, it's not uncommon for a heel spur to form on the bottom of the heel bone (calcaneus). This spur forms when the plantar fascia exerts excessive tension on the bone, and new bone is therefore formed, looking like a hook. As menacing as the spur can look, this is usually not the cause of the pain. Many people who have heel spurs do not have pain, and many people with plantar fasciitis do not have heel spurs. I feel the best way to accurately make a definitive diagnosis is the use of diagnostic ultrasound. Unlike x-rays which do a poor job of seeing soft tissue (such as the plantar fascia), diagnostic ultrasound sees the plantar fascia very easily. When plantar fasciitis is present, the plantar fascia will be thicker, especially near its attachment to the heel bone. If only one foot is symptomatic, patients themselves can easily see on the diagnostic ultrasound the difference between normal and abnormal plantar fascia. The other advantages to using diagnostic ultrasound include that it's available in office, is safe, and does not take a long time to perform.Once a definitive diagnosis of plantar fasciitis is obtained, treatment can begin. On upcoming posts, I will discuss the various treatments that are available for plantar fasciitis.

Monday, April 27, 2009

The Many Causes of Heel Pain

When someone comes into my office complaining of heel pain, the first thing that has to be determined is the underlying cause of the heel pain. Today I will briefly discuss the numerous reasons your heel can hurt. In the near future, each of these conditions will be discussed in greater detail. The types of questions you'll be asked if you're being evaluated for heel pain include:

  • Where on your heel are you having pain?
  • How long have you been experiencing these symptoms?
  • What activities make your symptoms worse?
  • What activities help relieve your pain?
  • Did you suffer an injury to the heel that was associated with the onset of your symptoms?
  • What things have you tried on your own to relieve your pain? Have any of these treatments helped?
  • Have you seen another doctor for this problem? If so, when, and what was done at that visit?
  • Are there any particular times of the day when your symptoms are worse?
  • What kind of work do you do? Are you required to stand or walk all day?
  • What kind of shoes do you normally wear?

Once these questions are answered, your feet will be carefully examined. In addition, x-rays will most likely be taken, and in many cases, a diagnostic ultrasound will be performed. X-rays help determine problems with the bone, while the diagnostic ultrasound is helpful in determining soft tissue causes of your symptoms.
Some of the more common causes of heel pain are as follows:

  • Plantar fasciitis - this is by far the most common cause of heel pain. Patients with plantar fasciitis typically report that their pain is greatest in the morning when they first get out of bed, then report gradual worsening of pain when they are standing or walking for prolonged periods of time throughout the day.
  • Rupture of the plantar fascia - a rupture of the plantar fascia is a painful event associated usually with a specific injury.
  • Fracture of the heel bone (calcaneus) - Major injuries aside, stress fractures of the calcaneus can occur without the history of an injury.
  • Nerve entrapment - the lateral plantar nerve can become entrapped between other structures in the foot, often causing a burning, tingling sensation.
  • Tarsal tunnel syndrome - this is caused by compression of the major nerve to the foot in the area of the ankle
  • Atrophy of the fat pad, or loss of natural cushioning beneath the heel bone - this lack of cushioning can be especially painful when patients walk barefoot.
  • Calluses, especially when associated with cracking of the skin - fissuring or cracking in the skin around the heels can be very painful. It is of special concern to diabetics or others who may be prone to foot ulcerations and infections.
  • Poor circulation - a lack of circulation to the foot can cause at times extreme pain due to not enough oxygen reaching the tissues. Pain from poor circulation often is present when one is walking short distances, and is relieved by rest. More serious cases may experience pain while lying down in bed at night.
  • Arthritis (including osteoarthritis, rheumatoid arthritis, gout, and many others)
  • Bursitis - this usually affects the back of the heel, at the attachment of the achilles tendon into the heel bone
  • Achilles tendinitis - The largest tendon of the body can become inflamed from overuse, and cause pain in the back of the heel
  • Bone spurs - bone spurs are common on both the bottom and back of the heel. However, it is usually only the spurs on the back of the heel that causes pain.
  • Sciatica - Pressure on the sciatic nerve in the lower back can cause pain along the entire length of the nerve, including in the heel.
  • Calcaneal apophysitis - this affects mainly younger, overweight or extremely active boys from the ages of 6 to 10.

Once your doctor determines the cause of your heel pain, steps can be taken to start a treatment plan that can get you back to feeling great!

Wednesday, April 22, 2009

Why write about heel pain?

It is rare for a day to pass in my office when I do not hear a complaint from a patient that they are suffering from heel pain. Often, it has been going on for quite some time, and by the time they see me, they've tried everything in the book, and some things that are quite creative to relieve and eliminate their pain. Quite simply, heel pain is one of the most common conditions that I treat, and also one that causes the most disruption to a person's life.

It would be nice if there was a quick & simple way to remedy heel pain that worked every time. This is not the case. The most common cause of heel pain is a condition called plantar fasciitis (and may also be known by some as heel spur syndrome), but this is by no means the only condition that can lead to pain in the heel. The first step is to find out what is actually causing the pain, then treatment can be tailored to eliminate the cause of the pain, and equally as important, to relieve the pain itself.

In the coming days and weeks, I will discuss what are likely reasons for a heel to be painful, how these conditions can be diagnosed, and what treatments are available to get you back to a normal life without pain. I will also be discussing what things you can do yourself at home to help relieve pain prior to seeing your doctor, and also what you can do once you are seen by a doctor to help you to recover more quickly. Feel free to follow along, and add your comments or questions. The good news for the vast majority of patients, heel pain is treatable. The process may take awhile, but there is light at the end of the tunnel!