The calf muscles are attached to the heel by the Achilles tendon. This is primarily the thickened cord or fibrous band that runs down the back of one’s leg and attaches to the heel bone.   The main function of this complex is to force the foot downward in gait and thus propel one forward.  Achilles tendonitis is a common diagnosis for all podiatrists and Dr. Sowell is no different.  Athletes, housewives, factory workers and professionals are just a few of the types of patients who suffer from Achilles tendonitis.  The cause may be varied.  Sometimes it is to injury from a direct impact, from over-use or excessive training, or can just start hurting as a result of shoe pressure.  The patient with an Achilles tendonitis will most often have pain and swelling in the lower portion of the tendon just above the heel, will have discomfort when moving the foot upwards thus stretching the tendon, and will probably note that the condition has worsened over time. 

It is hard to predict who will suffer from Achilles tendonitis but there are certain factors, which seem to be likely.  Trauma or injury to the Achilles tendon itself is an obvious cause of subsequent tendonitis.  An altered gait, high heels over a long period of time or limb length discrepancy can also create excessive strain upon the Achilles tendon resulting in localized swelling and pain.  Over use, excessive training and improper stretching can also result in Achilles tendon injuries.  The bottom line though, in most cases of Achilles tendonitis, is the same…pain, reduced range of motion, localized swelling, and a potential long-term problem that is usually slow to respond to therapy.

In discussing the treatment approaches to an Achilles tendonitis, we must first mention the necessity of a thorough examination by a specialist.  Fractures of the heel bone, partial ruptures of the tendon itself, and localized soft tissue problems must all be carefully considered and ruled out.  The specific treatment of an Achilles tendonitis might include physical therapy, shoe padding (lifts to raise the heel), possible orthotics, oral anti-inflammatory medication, some form of immobilization, and reduced physical activity until the condition improves.  Surgery, although mentioned for completeness is rarely used.  It should be mentioned that this painful and often disabling condition, while frequently slow to respond, will usually improve and resolve with therapy over time.

Patients often find themselves in a “catch 22” where the tendon needs to be lengthened through a progressive stretching program but said program only aggravates the condition.  With careful diagnosis and addressing of symptoms, Dr. Sowell can determine the best way to proceed and hopefully return the patient to activity sooner than expected.

Every year I see a dozen, or so, young athletes that are having problems when playing.  Typically they are running on their toes to avoid heel pressure and play explosive sports with increased heel pressures.  Of course these children need to be assessed and properly diagnosed to rule out more severe conditions, but I want to discuss calcaneal apophysitis today as spring begins!

We can often learn a good deal about a particular medical condition if we understand the terminology used in its description.  The term, calcaneal, refers to the heel bone while apophysitis describes an inflammation of the heel’s growth center in a child.  A calcaneal apophysitis is a condition usually seen in young athletic or physically active children of the age group 8-15.  The heel is painful with running or jumping, is usually not swollen visually or discolored, and seems to get progressively worse without treatment.  A parent will often bring in a child because of limping during game play along with complaints by the child of discomfort in and around the heel.

Most authorities seem to agree that this condition results from acute or chronic (repetitive) trauma to the heel at a time of vulnerability due to natural growth periods.  It should be noted that the heel area of the foot is under normal circumstances, not highly vascularized or well supplied by blood circulation.  This means that the area of the foot will heal slower and might be subject to increased risk of injury.  Acute trauma refers to a sudden impact or blow to the involved site while repetitive trauma involves cumulative stress over an extended period of time.  The bottom line is similar however, with trauma to the growth plate area of the heel being the culprit.

The management of a calcaneal apophysitis condition involves protection and support of the heel in order to allow for normal developmental growth.  This can be accomplished by padding the heel of the shoe, wearing protective cups, and in some cases to even further reduce weight-bearing by casting and or crutches.  Often I’ll recommend alternating NSAIDs and applying ice before and after activity.  The continuance of athletic competition during treatment is an issue that is largely dependent upon how the child responds to therapy initially.  In most cases, where the symptoms reduce early on with treatment, the child might continue with physical activity.  On the other hand, if the symptoms persist well into the therapy period, then reducing or eliminating continued physical activity might be necessary.  This condition in most cases, can be readily managed once identified and properly treated and almost always resolves over time.

One of my favorite ways to ice the bottom of the foot, particularly the plantar fascia, is to freeze a water bottle.  Simply  take a water bottle, throw it in the freezer and let it freeze.  Every day after that, simply place it on the ground in front of you (on its side) and roll it back and forth like a rolling-pin.  Roll it from the ball of the foot back to the pad of the heel.  This will completely cover the length of the plantar fascia and should relieve the symptoms of its swelling.  If you press downward on the bottle, with your foot, while you roll it back and forth you also get a pretty good massage along with the effect of the ice.

The plantar fascia is a dense fibrous band that runs along the plantar surface (bottom) of the foot and is fairly easy to recognize.  Simply lift the big toe and the medial slip of the plantar fascia will become more prominent in the arch and if you follow it back to the heel this is the most common place for the plantar fascia to be painful.  Most people with plantar fasciitis have pain when the get up in the morning or when they get up after sitting for a few minutes.  Hope this helps!

I recently posted a foot pain discussion of Achilles tendonitis that I feel helps a patient suffering with pain on the back of the heel understand what might be going on.  However, there is a diagnosis in the same anatomic area that often gets confused with Achilles tendonitis and I thought I should discuss it today.  Retrocalcaneal bursitis refers to a fluid filled sac (bursa) that rests behind (retro) the heel bone (calcaneal).  This bursa has the unenviable job of cushioning between the heel bone and the Achilles tendon.  When this bursa becomes inflamed we call it bursitis.

As a podiatrist in Nacogdoches Texas, I see all types of patients with this painful condition but there is one type I seem to see more than others.  This patient, I think, makes a good example for our discussion and should help us better understand the condition.  I am speaking of the newly retired cowboy!  Lol.  This patient has worn cowboy boots for fifty years, usually with a pretty good heel on them, and has now retired from his work where the boots were required.  So, he has begun wearing tennis shoes more and unknowingly began a mechanical condition that will lead to pain.

After years of wearing an elevated heel in a shoe, or boot, the tendon becomes adjusted to the length needed in that particular shoe.  Over years it can become much shorter and if not stretched properly over those years it can have significant difficulty adjusting to its new environment in a tennis shoe.  As the heel gets lower, the pressure between the tendon and heel bone increases and the bursa becomes irritated.  I also see this in athletes who have been making their calf muscles bigger but not stretching them properly.

Treatment, after proper diagnosis, usually consists of ice, NSAIDS, physical therapy or steroid injections for the swelling and at some point will include a stretching program to lengthen the tendon.  Heel pads and lifts have also been proven to help the situation.  Of course, proper assessment is the key and is why I feel a podiatrist is necessary in all conditions concerning the heel.