Relieving Heel Pain with Cryoablation

BioMechanics: Nerve Entrapment Puts The Pinch On Heel Pain

Evaluating patients for nerve problems aids practitioners in treatment decision making
By Gregory Mowen, DPM

Heel pain has been one of the most common presenting complaints that podiatrists, orthopedists, and sports medicine specialists encounter. It is conservatively estimated that two million patients in the U.S. seek treatment annually for heel pain.

Patients have a variety of conservative treatment options, including nonsteroidal anti-inflammatory drugs, physical therapy, cortisone injections, orthoses, and night splints to relieve their heel pain. When these conservative options fail, practitioners often turn to alternative treatments.

Many practitioners do not evaluate their patients with heel pain for nerve entrapment. Those who do test will often first rule out all other factors. Another frequent delay in testing for nerve entrapment is that symptoms may not always be consistent. A Tinel's sign (distally radiating paresthesia in response to gentle percussion) may not always be present as expected in nerve entrapment syndromes.

Pressure-specified sensory testing
A relatively new method for determining peripheral nerve involvement in the upper and lower extremity is pressure-specified sensory testing. The Pressure-Specified Sensory Device (Sensory Management Services, Baltimore), invented by A. Lee Dellon, MD, a pioneer in diagnosing and treating peripheral nerve problems, is noninvasive. It can measure light touch, two-point discrimination, and one- and two-point moving pressure thresholds. Normal levels are preloaded in the system's software and then used for comparison. Diagnosing peripheral nerve problems with PSSD has shown high rates of clinical accuracy.

In a study of 82 patients, Rose et al used pressure-specified sensory testing to evaluate patients presenting with typical plantar fasciitis pain. They concluded that 72.17% of the patients had abnormal sensory function around the heel.

In a sensory testing study, other traditional tests were compared with PSSD and were found to be far less reliable and less sensitive. Using PSSD to identify a peripheral nerve problem was 100% accurate; Semmes-Weinstein monofilaments were only 63% accurate; and vibrometry achieved only 30% accuracy.

Testing each peripheral nerve in the lower extremity for pressure threshold and for two-point discrimination is advised. The results can then help determine a more effective course of treatment. For instance, if there is no neural involvement, then chronic fasciosis should be addressed.

Cryosurgery
If there is isolated nerve entrapment of the MCN (nerve on the inside of the heel) and conservative care fails, then either open decompression of that nerve, endoscopic decompression,or cryoablation would be appropriate. We prefer to use cryosurgery to ablate the terminal branches of that nerve. Cryosurgery is a minimally invasive office procedure that has shown success rates of about 90% among chronic plantar heel pain patients.Typical care for fasciitis/fasciosis may still be needed because of the multiple factors often involved with heel pain.

Most of the common complications associated with an open procedure are not seen in cryosurgery. Typically, after this procedure, the overwhelming majority of patients have less pain and a shorter healing time; they can engage in their activities of daily living immediately. Cryosurgery also can be easily repeated if the patient doesn't achieve complete relief.


Conclusion
Nerve entrapment plays a common role in most heel pain patients. It appears that an incredibly high percentage of people with plantar heel pain may also have nerve entrapments. We need to look for nerve entrapment in these patients much earlier in our evaluations. Knowing more of the factors involved with the patient's pain can lead to more effective treatments.
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Dr. Esther Lyon D.P.M. is a Board Certified Podiatrist who practices in the Western suburbs of Chicago, Illinois. Heel pain is the most common foot ailment she treats at her offices in Lombard, Warrenville, Wood Dale and Elgin. Cryoablation has been an extremely effective treatment modality in helping patients with foot and heel pain. To schedule an appointment, call (630) 495-1240. We care about our patients.

Suburbs adjacent to Western Suburb locations, include: Glen Ellyn, Wheaton, Elk Grove Village, Schaumburg, Addison, Downers Grove, Elmhurst, Naperville, Aurora, North Aurora, West Chicago, Batavia, South Elgin, Bartlett.

Dr. Lyon D.P.M. started her practice in Lombard in 1997 and is a Board Certified Podiatrist by the American Board of Podiatric Surgery.