Medial calcaneal pain.

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Happy new year all.

Had an interesting patient in today.

13 year old boy

Pain in his left heel.

O/E valgus sag,stj medially deviated,FHL,Gastroc equinus,Intoing gait.

Pain was elicited on direct palpation to heel border on the medial aspect producing a tender sensation which faded into a tingling sensation.The sensation radiated into the arch area.

P/f was tight and pain at medial calcaneal tubercl was produce with hallux dorsiflexion and palpation to site.

Patient is very active participating in jumping and sprinting activities

Poor muscle strength in passive forefoot d/f and inversion.

I have concluded p/fasciitis and compression of the medial plantar nerve secondary to medially deviated stj.

Any comments?

 

It sounds like a common thing which I see with active kids sometimes more prevelant in the growing years. I would have said p/f is uncommon with kids but in the past 3 months I have seen a few myself, boys between 10-13 years playing soccer at a high level.

I have had reasonable success on these types with a semi-rigid device, I used high density plastizote with EVA posting/midfoot support. He would do well with a heel raise I believe. Is his "malalignment" bilateral? If so, what one does for one side , do for the other. Check LLD's, footwear...(is it part of the problem?skateboard and soccer shoes), stretching routine to improve sagital stretching of the gastroc soleous muscles.

I have not tried as much initally to completely support the medial long arch, (crank it as some have called it)rather, if they are equinus, lower it. I also do a longditudinal groove for the prominent fibres of ther p/f and flexor hal.l tendon,. 1st met cutout, 2-5 or a kinetic wedge to unweight the first. I do try to bring them to subtalar neutral with posting, but I would not do a medial skive. I don't wish to increase pressure at the sore area. I very often will put a poron cushion (1/8") under the heels and blend its anterior edges so they are not bothersome.

I believe it is important to make sure theses kids are not wearing skateboard shoes to hang out in. If they are athletes, they should be in stable footwear at all times, wearing their orthotics. When they not are not training, they are supposed to be recovering. If they are not recovering in a the best alignment available to them, they are not recovering. If they insist they are going to wear their skateboard shoes, stick an additional heel raise in until they begin to function better. Some skateboard and soccer shoes, have zero heel elevation which is a key point in managing patients having equinus related problems.

Last comment, I have some excellent physiotherapists with whom I have good working relationships. They are like gold to me and my patients. I use them a great deal to help speed along the healing.

Best regards,
Freeman

 

Just added to Freemans response, I would also do a slump test to rule out any proximal neural pathology.

I also had a similar case last year ....whole range of "odd" "neurological" symptoms assocated with heel pain that did not fit the typical pattern for things like medical nerve entrapment etc and I went looking for all sorts of weird and wonderful diagnoses ... ending up deciding it was actually just Severs (which the student told me it was that in the first place!), treated it as such and they got better.

 

Freeman.

Your prescription almost identical to the one that I have done.Great minds think alike!

Thanks

Scott

 

Scott,
I will be curious to know how he gets along.
Best wishes
Free

 

Can anyone advice me on how to manage a 63 year bus drive with pain in the calcaneal tendon area. He is over weight and does very little excerse. He is experiencing pain when he climb stairs.
Regads
Georgia