Heel pain can be a really crippling problem at all ages and especially for adult males. I have recently had an email from a 60 year old man complaining of heel pain.
He described "sharp shooting pains in the left heel area. Usually when it comes under tension – even slightly, say from bending at the waist – or on impact – even the slightest."
He went on to explain the pain as "odd, insignificant, but very sharp when it occurs." He had only become aware of the pain in the past few days and said that the only change of habits was that he had started doing quite a lot of swimming. He didn't indicate that he had had any injury.
My first thoughts were a series of questions:
- "Do you have any lower back pain?
- "How strong are your abdominal muscles?"
- "Does it come on spontaneously when sitting in the car or at the computer?"
- "Do you have any residual joint damage from sports injuries or osteo-arthritis?"
Shooting pains like this are usually associated with nerve entrapment, pinching, or tight muscles like the hamstrings. At this age, osteoarthritis of the spine is a common cause. However, in this case, I suggested that the pain could be associated with the new range of movement since he started swimming.
Treatment for heel pain, begins with trying to find the cause, including the possible underlying cause at this age of being overweight, with a protruding belly! Not so in this case. Bearing in mind that this was an email communication and the symptoms were clearly described, I suggested the following:
- Start by gently stretching your lower back when lying on your back on the floor
- In this position, with knees bent and feet flat, roll gently side to side, all the time pressing your lower stomach into the ground
- In the same position, curl your knees up to your chest
- Another fun exercise is to kneel on all fours; extend your left arm out in front and your right leg out behind you; hold this for 10 seconds and change sides!
- A Physiotherapy consult is advisable at the same time
A few days later, the gentleman diagnosed the problem as tension-related. He actually tried a rather risky move - "I can provoke sustained pain by crouching and then arching my back to put the whole back, rear leg muscles under tension."
Luckily he was able to get up from this position, not call the Fire Brigade to lift him up and take him to hospital!
There is no apparent foot problem of pronation or flat feet, so it does sound like a nerve – related problem.
Then out of the blue, another man of similar age visited the practice with similar symptoms. By me moving the foot into certain positions that stretched his lower back, I was able to reproduce the burning, shooting and tingling pains he complained of.
Doing some research on heel pain reveals many causes; nerve entrapment is one of the more difficult to diagnose.
When an Achilles tendon ruptures, the patient may tell you they heard a sound like a gunshot and they cannot walk, but with an Achilles tendon tear it is still possible to walk around without knowing your injury.
This week a lady consulted me complaining of pains at the back of both heels and into the calves, which had been there for more 6 weeks. She experienced aching, throbbing and a stretching sensation, especially in the evening. She felt less pain wearing higher heeled shoes. In addition, the pain was worse when she got up after sitting for some time.
There was a history of a right ankle fracture and some persisitent left knee pain. She also told me that she had been diagnosed with calcaneal spurs many years ago. The lady was overweight and of short height.
During my examination, I could see and feel that both Achilles tendons were swollen and had nodules in them. Her walking stride was short and stamping. There were other significant biomechanical problems too.
Temporary treatment consisted of in-shoe wedging. I also referred the lady for an ultrasound scan of the Achilles tendons.
Two days later the scan reported the left tendon as having "….an almost full thickness intra-tendon tear ……approximately 2.8mm thick, extending 30mm longitudinally." On the right "……loss of fibrillar pattern, consistent with fraying."
There were other features, but this was one lucky lady, because there could have been a rupture at any time. This time she was referred to an orthopaedic foot surgeon.
So whether you are a patient or podiatrist, when managing chronic pain at the back of the heel, consider the benefits of ultrasound scanning to assist in diagnosis and always act quickly, you might discover an Achilles tendon tear.
Choosing the correct footwear for walking is very important. With the Talk Radio 702 Walk the Talk coming up this Sunday 26th July, there will be 50,000 people strolling, walking, meandering, marching and even racing through the streets of Johannesburg.
The most important thing is to keep to the footwear that you have been using, don't treat yourself to a new pair of trainers for the day, because although they may feel quite good at first, they need a bit of wear to 'bed in'.
Walk the Talk 2009 - Click to Enlarge
I suppose that there will be some serious hikers/walkers in the race and they will know that the best footwear is your regular well worn (not worn out) footwear. If you are walking, just for fun, in your old worn out trainers, you might be better to walk in your most comfortable more formal shoes!
A firm but cushioning sole is best. Firmly laced, not too tightly, because your feet will swell a little and if laced too tightly, the lacing and tongue will press on the nerves on top of your feet, making them numb or tingly.
If you do get these symptoms, stop and re-tie your laces, rather then get pain. The fit around the heel must be close, so that there is no excessive sliding of your foot, because excessive sliding or shearing causes blisters.
Choice of socks is very personal. Thick or thin they should be able to absorb some of the sweat that you are going to shed. It's worth using a thicker cotton sock rather than a woollen one.
Although many walkers and runners use no socks or even the feet out of stockings, again use what you are used to.
If you have been getting blisters during your preparation for the race, try putting a 'blob' of Vaseline over the place that blisters, it works as a lubricant and will reduce the risk of blistering.
An alternative is to cover a sensitive area with plaster, just beware of putting it where it could roll up and cause a sore spot.
Tactically, watch out for getting sucked along at a faster pace than you want to, or are able to go. This is one way to pick up an injury and get painful feet. You must try to keep to your own pace.
After the race, if you have blisters or any foot problem, look out for the University of Johannesburg Podiatry Caravan and treatment area, they will be able to help with most foot problems.
The Biennial Congress of the South African Podiatry Association took place this last weekend.
The first two days were a Biomechanics Boot Camp taught by renowned Australian podiatrist Craig Payne and today there were presentations by local podiatrists on rheumatology, diabetes, paleo-anthropology and education.
Most podiatrists routinely perform biomechanical examinations on their patients – but this Boot Camp was something else – it has changed my thought paradigms and will alter the way I examine my patients and any orthotic treatment I decide to use. (I know this is true for every one else who attended the Boot Camp).
There was another interesting development at the Congress, I was elected Chairman of the South African Podiatry Association for the next two years.
This is a real privilege and challenge as podiatry in South Africa needs to have a much higher profile and take a more prominent place in the South African health care scene.
Expect to see much more about feet and foot care in the future.
