PRESENT Featured John Vanore, DPM Heel Pain

Apollo, to the warrior Paris, " Why do you waste you arrows on insignificant targets? Serve your people better. Take your revenge on your slaughtered brothers. Kill Achilles!"
Metamorphoses Book 12

Following the birth of her newborn son, Achilles, Thetis was told of a prophecy that her son will be cut down in war. In an attempt to protect her son, she brought him to the river Styx and dipped him in the black waters. At that moment, Achilles' entire body became impervious to weapons. Only his heel, the part where his mother had held him, was left vulnerable by the river. This being the only part of his body that could be wounded.

Achilles was the foremost hero of the Trojan War. His valor on the battlefield was known far and wide. At the beginning of the war, Achilles killed Cygnus, the son of Poseidon. To avenge the death of his son, Poseidon sought help from Apollo. Apollo agreed to help the heart broken "God of the Sea" avenge the death of his son.

While Achilles was ravaging Trojan warriors, Apollo located Paris on the battlefield. His divine intervention allowed an arrow shot by Paris, to find the only spot on Achilles' body that was vulnerable. His heel!! Achilles died of his wound.

This stellar lecture by John Vanore, discusses the etiology and treatment of Plantar Heel Pain. The majority of patients with heel pain present with pain at the insertion of the plantar fascia into the calcaneal tuberosity. They usually report pain after periods of immobility and after extended periods of weight bearing. The discomfort is commonly brought on by increased activity levels, weight gain, poor biomechanics or improper shoe gear. It is essentially an overuse injury, magnified by these risk factures.

Plantar Fasciitis is seen so commonly in our practices, representing over 50% of patient encounters, that we often neglect to consider the tremendously varied etiologies that can cause heel pain. Dr. Vanore reminds us to carefully work up the patient with atypical or recalcitrant symptoms. Remember to consider the seronegative arthritides, neurological entities, fractures or even neoplastic lesions in your differential diagnosis. When was the last time you thought about Reiter's disease and the "fluffy periostitis" seen in the heel, or entrapment neuropathy of a calcaneal nerve. Stress fractures of the calcaneus are not uncommon either. Slide 43 of the lecture demonstrates a rather large neurolemoma. Its worth the look.

Dr. Vanore recommends a highly organized and reproducible "stepwise" or "tiered' approach to heel pain. 90%-95% of patients respond to conservative approaches in the first or second tier. It is important to recognize patients who have biomechanical faults and provide them with a well made orthotic before considering the more aggressive therapies in the third tier. These therapies should be reserved for patients who continue to experience significant symptoms and disability despite 3-6 months of appropriate care.

Dr. Vanore describes the various options that are available for the patient with resilient heel pain today. ECSWT, Endoscopic Plantar Fascial Release, open and percutaneous fasciotomy are all viable alternatives. Which technique is best? Let Dr. Vanore help you decide.