Treating Heel Pain
Heel pain is a common problem that many podiatrists see daily in their busy practices. As foot and ankle physicians, we treat this malady quite frequently with a variety of treatment methods. Before we concern ourselves with the actual treatment plans, let us understand a little background information about this condition.
What is Heel Pain?
Heel pain commonly refers to a number of conditions that can affect the heel. For the layman, it is an umbrella term that can mean a whole host of issues. For argument’s sake and brevity, let us focus on what is more correctly referred to as “plantar fasciitis” or inflammation of the plantar fascia. This entity goes by many other names, such as heel spurs, heel spur syndrome, plantar fasciosis, to name a few.
The plantar fascia is an elastic band of tissue that spans between the heel and ball of the foot. It actually continues as the plantar part of the Achilles tendon, beginning behind your leg, around the back of your heel bone, and continuing to the bottom of the foot where it separates into 5 smaller parts to insert onto the bottom of the foot where each toe connects. Normally, this fibrous band of tissue is able to withstand the years of punishment that we put our bodies through daily. It actually does quite an amazing job, supporting our arches as we walk, run, jump, dance, and generally abuse this portion of our anatomy. We don’t really think about our feet until they begin to hurt. And nothing hurts more than a sharp, stabbing pain at the heel which is worsened with every step. We are constantly reminded how much it hurts as we plod through our work day. And when you rest, it feels better, right? But then you get up off that work chair and hello that lightning like pain comes back even stronger than before. More about that later.
Before I continue, a small disclaimer is needed. It is important to note that heel pain can be due to a variety of other causes. Because of this, it is important to have heel pain properly diagnosed by a foot and ankle physician, someone who is best trained to determine the appropriate diagnosis and treatment.
For plantar fasciitis to occur, we need to understand mechanically what is happening. I like to tell my patients to think of a rubber band that is attached to two sides of a roman arch. The rubber band stretches and tightens, stretches and tightens, and so on throughout the day. To cause pain, this rubber band stretches beyond its normal length. The tissue becomes inflamed because of the excessive stresses placed upon it. Unlike a rubber band, it doesn’t snap, but it sure does feel like it. In the body’s futile attempt to “bridge the gap,” sometimes extra bone is laid down where the band begins at the heel. Thus, we arrive at the term heel spur. Instead of alleviating the pain, this oftentimes exacerbates the pain, prompting a visit to your local podiatrist.
Signs and Symptoms of Heel Pain
Signs and symptoms that you may experiences include the classic “post static dyskinesia.” This term really means “it hurts when I begin movement after a period of rest.” The most common complaint I hear is “doc, my feet hurt as soon as I place them on the floor in the morning.” Think for a moment back to the rubber band. While you are sleeping at night, your feet are resting on your bed, and very little, if any, stress is placed upon them. During the night, that rubber band tightens and gets smaller because the roman arch of our foot does not need to be maintained during a period of rest. But when we wake up in the morning, bright eyes and bushy tailed, we throw our feet over the bed onto the floor and OUCH! We have suddenly and abruptly placed a stress on that foot. This doesn’t occur just in the morning either. It can occur after ANY period of rest longer than two or three minutes. Sometimes, this pain is diminished a bit after that initial first step because the fascia is being forcibly stretched.
Other symptoms include specific pin point pain at the heel, which often is easily noted. The pain often worsens as the day continues and is very quickly alleviated with rest. Also, the pain may progressively worsen over a period of months. Certain shoes may aggravate the condition as well. Obesity, shoe gear, work conditions, and foot type can all play a role in its development.
Conservative treatment is the mainstay of eliminating heel pain. Any number and combination of the following methods may alleviate your pain. They are basically divided into what you can do as a patient and what we can offer as physicians.
Stretching is Key
The most important component I believe is stretching. Take a belt, a towel, or that ugly tie Aunt Sallie gave you for your birthday and stretch your feet every day BEFORE getting out of bed. Put the towel at the ball of the foot and pull both sides toward you like a horse bridle while keeping your knee straight. You should feel a pulling sensation behind your knee and down your leg. Hold this position for 30 seconds and repeat five times with 30 seconds rest between each stretch. Oh, and make sure you stretch the unaffected side as well. I’ve seen it go away on one foot only to return on the other.
Another trick is to freeze a regular ole’ bottle of water. Every night as your sitting in front of your television watching the news, roll that bottle with your foot for about ten minutes on each foot. This ices the bottom of the foot and stretches the fascia at the same time.
Nonsteroidal anti-inflammatories, or NSAIDs for short, are also a great option for some. Advil, aleve, celebrex, naprosyn, ibuprofen, motrin, etc. are over the counter and readily accessible for all patients. Your doctor may prescribe a more potent NSAID but they all help to reduce inflammation and swelling associated with this condition.
I can’t encourage you enough to wear shoes at all times, not just at work or play. Many houses have tile or wooden floors which will not offer any cushion to that painful heel of yours. Wear supportive sandals or thick flip flops around the house. I try to discourage house slippers because they are really not helpful. I prefer that my patients wear Crocs because they feel wonderful and offer just enough support to be worn around the house. Along that same line, I can’t over emphasize the importance of quality shoe gear. A good supportive shoe will do wonders. You cannot believe the type of shoes out there and I often find myself asking “you paid HOW MUCH for those?”
Moving into the doctor’s office, we have a variety of more in depth treatment options. Any good doctor worth his weight will give you a crash course on the conservative treatment options above. He may also offer to tape your feet, temporarily lifting the arch and assisting that rubber band. This works great but unfortunately, unless your doctor is your spouse, only lasts a few days because the tape falls off.
Night splints are somewhat expensive but they also work wonders. Maintaining the stretch on the plantar fascia during the night while you sleep certainly assists with pain control and condition remedy, but they can be awkward and some people may not be able to tolerate them. Your doctor may elect to have you wear a removable walking cast or boot that can be used to keep your foot immobile for a few weeks to let it rest up and heal (pun intended). Another item that can provide very long lasting relief is custom orthotics. They are expensive but ask anyone who has a pair, they are definitely worth it. These address the underlying structural abnormalities that may be contributing to your heel pain.
Injections seem to be the mainstay of our treatment regimen because they provide quick relief. They can be somewhat painful when administered, but offer long lasting relief when they take affect. They are usually composed of a short acting local anesthetic as well as a longer acting corticosteroid, which serves to reduce the inflammatory response.
You may also look into shockwave therapy which has been shown to have excellent results. As a last resort, surgery is an enticing option for some. More than 90% of patients routinely achieve lasting relief without surgery. You should try at least six months of conservative measures before entertaining the idea of surgery. Your foot and ankle surgeon will discuss the most beneficial approach for you.
No matter what treatment you undergo or receive for this sometimes very painful condition, remember that the underlying causes of this condition often remain. Therefore, you should proceed with preventative measures to reduce the chance for recurrence. For all patients, wearing supportive shoes and using your custom molded orthotic devices will provide long term treatment.