What happens when your patient returns and his/her heel pain has not improved?  Do you assume that physical therapy didn’t work?  What you CAN conclude is that your patient may not have received the RIGHT physical therapy.

Heel pain is multi-factorial.  What needs to be determined in physical therapy is whether the origin of the pain is local, referred, or both.  As our patients become heavier, more de-conditioned, and more susceptible to concurrent orthopedic dysfunction, the chance of referred symptoms from discogenic involvement and/or peripheral nerve entrapment is greater.  If our patients at OrthoWell/WalkWell are not significantly improving after 4 visits of localized soft tissue treatment, then referring sources of pain need to be considered.  If nerve involvement is suspected, then it is easier to perform manual differentiation testing after the nerve has been sensitized.  Our patients are instructed to return to PT when they are most symptomatic.  Neural tension testing of the sciatic nerve may elicit heel pain or a “doorbell” sign may be elicited along the course of the sciatic or tibial nerve.  See below.

Our patients may be susceptible to the “double-crush” phenomenon due to concurrent areas of nerve entrapment.  Centrally mediated entrapment may arise from a history of disc herniation or multiple lumbar disc sprains.  Common peripheral entrapment sites are the lateral plantar nerve at the medial heel, the tibial nerve under the flexor retinaculum in the tarsal tunnel or as it courses through the tendinous arch of the soleus, and the sciatic nerve at the distal split of the hamstrings, between the biceps femoris and adductor magnus, or under the piriformis muscle.  Active Release Techniques, as performed at OrthoWell/WalkWell Rehab, are very effective in resolving these entrapments.

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