Wednesday, March 19, 2014

Secrets of Recurring Heel Pain

Many patients are becoming even more active with age, and as this new generation of elderly patients become our community's senior citizens we are finding out more often that you are only as young as you feel. With this, there are different aches and pains, and they are more common and can be restricting towards maintaining this level of leisure. Above all other pains common to the foot and ankle, heel pain is by far the most common. Sometimes, we will be a 3rd and 4th opinion to attempt to remove this nuisance from our patient's feet. Most often heel pain is treated by cortisone injections, physical therapy, weight loss, and orthotics. 

But what about the patients who have been there and done that?

There are few treatments that are more promising in the field of heel pain management with more potential than the

Extra Corporal Shockwave Therapy for very tough heel pain. A good overview of the proposed mechanism for how this works involves using devices that generate pulses of high-pressure sound that travel through the skin and yeild natural repair from the tissues and increased blood flow networks to damaged tissues. 

For reasons that are not fully understood, soft tissue and bone that are subjected to these pulses of high-pressure energy heal back stronger and without causing further damage to the tissues like repeated cortisone injections may do. 

The FDA has approved the use of some ESWT machines for heel pain and tennis elbow. ESWT devices evolved from lithotripters (a.k.a. kidney stone shock wave machines). The discovery of the beneficial effects of ESWT came as German researchers were trying to determine what type of high-pressure pulses could be sent through the body to disintegrate kidney stones without causing harm to surrounding tissue. In laboratory animals and humans, it was discovered (with some surprise) that surrounding tissue would often heal back stronger and this applies well to our topic of heel pain. 

Physical therapists use ultrasound machines that warm internal tissue by high frequency sound waves, but the ESWT machines send higher-energy pulses 2 or 3 times per second rather than continuous lower-energy waves. Electricity is not sent into the body. It may take as long as 5 months to see the full benefit of an ESWT treatment. The beneficial effect of the high-pressure waves may be from the growth of new blood vessels ("neovascularization") in small cavities that are created by the pulses. New blood vessels to an area of tissue would promote healing either directly or indirectly by providing additional growth factors to the area of concern by way of new vascular channels.

Some studies have even shown this therapy to be equivalent to a fasciotomy, which is an invasive procedure that involves an incision to sever the medial fibers of the fascia for reduced pressure and tension on the inferior heel bone. This means that you can get equivalent results without the complications of a minor procedure. We can provide ESWT that has benefits that have been shown to work well on difficult heel pain. This can be beneficial to our patients, and if you are limping in the AM, or have trouble walking after a brief rest from activity because your heel is holding you back, you should consider a consultation with one of our doctors.

Achilles Pain ?

1) NOT all posterior heel pains are tendon problems.

We will provide a thorough examination, which includes radio graphs, and clinical exam with history taking to provide the best possible outcome for your pain. There are several other structures which are present and could be treated in a different manner than any straight forward Achilles tendinitis. Noted above, there is a bursa which is present here and can often be the root cause of pain secondary to bursitis. This is treated differently than Achilles tendinitis. This may also require MRI to determine how much of the inflammation is related to bone versus soft tissue. Additionally, and more rarely, a stress fracture can cause this pain in the calcaneus. This is not common but we check for this as well.

2) Tendon tears do NOT always require surgery.

After clinical examination and proper staging/grading of the extent of the tear, we have had success in treating Achilles partial tears and even ruptures non-surgically in select patient populations. We have a variety of techniques at our disposal in order to facilitate the healing process if surgery is not indicated. In the case of chronic tears there are several nonsurgical treatments that work, particularly PRP injections, High energy shock-wave treatments, and even physical therapy with anti inflammatory ultrasound.

3) Bone spurs are NOT always relevant.

Often times patients will state that they "Have had a spur in the past but it went away". Usually any bone protuberance which is either palpable or visible on a plan radio-graph or MRI will NOT go away spontaneously ever and always if indicated will need resection if it is the root cause of the symptoms. In most cases the spur is not the root cause of the symptoms, and is not required to remove it, but there are far too often very large spurs which are not even symptomatic that are visible on X-ray examinations in many of our patients, therefore backing up further the concept that bone spurs are not always the real problem.

Bio-mechanically a bone spur will exist in areas of either repeated chronic trauma, or areas of chronic taut insertions. Rarely is this an isolated tumor of bone, and that being said, it is often not necessary to remove the bone spur.