Please comment on cryotherapy to sensory nerves to treat heel pain.   Yours, Dwight L. Bates, DPM, DABPS

The utilization of cryotherapy to produce "pain relief" of a patient's heel pain runs counter-intuitive to my management of heel pain. I am not saying that this may not have a place as a surgical measure of "last resort." I have even seen the utilization of posterior tibial nerve neurectomy in the eventual relief of a patient's heel pain, but only after exhaustive conservative management and rule out of systemic diseases and rule out of lower back radiculopathy. My concern in regard to this procedure is that the symptomatic relief of the patient may be accomplished without the etiological work-up. In addition, such a procedure may produce a region of  anesthesia/ nerve loss which may predispose the pre-diabetic/diabetic obese patient (many with heel pain) to ulcer/wound development. My concern is that the relatively "simple" surgical procedure may have a propensity for over-utilization.
I am faced with a similar dilemma in my practice many times per month. The patient may have been diagnosed with a "neuroma" by another physician. Upon careful examination, the patient demostrates pain upon compression of the plantar aspect of the metatarsal head. The patient with this "neuroma" does not reveal a Mulder's sign, Valleix phenomenon or Tinel's sign with compression of the the intermetatarsal nerve plantarly. MRIs may be not helpful and diagnostic ultrasound studies reveal hypoechoic regions of edema. However, these patients demonstrate "numbness or burning" with prolonged walking/standing at the end of their day. Does this patient have a classic neuroma? My feeling is that the patient may probably be experiencing a metatarsalgia with secondary neuritis due to regional edema and trauma from the metatarsal imbalance (increased weight bearing stresses.) Therefore, if one were to remove this "neuroma" was there an etiological evaluation and treatment of the patient's pain? The patient  may feel better just because of the "neurectomy."  The imbalance of the metatarsal with subsequent infraction of the joint  would not have been prevented without addressing the metatarsal imbalance if this is the primary pedal etiology of the patient's pain.