HEEL PAIN

It is estimated that 15 percent of all adult foot complaints involve heel pain.  Heel pain from plantar fasciitis and heel spurs is characterized by sharp pain, aching, or stiffness on the bottom of one or both heels. The pain is often (not always) worse on the first few steps out of bed in the morning or after sitting down for an extended period then attempting to walk. As the condition progresses, there can be pain with every step. Heel pain originates deep within the foot, directly under the heel bone within the connective tissue. The pain is caused by excessive pull of a very thick ligament called the plantar fascia. This ligament's function is to help support the arch. When the arch depresses or flattens out more than the ligament can withstand, the ligament pulls or tears away from its attachment into the heel bone (calcaneous). At this stage, the condition is known as plantar fasciitis.  As a result of this tear, the heel bone develops a rough surface. After several of these tearing episodes, a heel spur is formed on the heel bone and the condition is called heel spur syndrome. We have found that the presence of the spur is not the cause of the pain. The pain is actually due to an excessive pull and inflammation of the plantar fascia caused by flattening of the arch. In most cases heel pain can be relieved without surgery.

What Causes Heel Pain?

• One of the most common causes of heel pain is a sudden change in physical activity.
• A change in jobs  from one that was primarily sitting, to one that is primarily standing and walking is a very common event that leads to heel pain. 
• Taking up a new sport such as tennis, jogging, aerobics, dancing, or even exercise walking can result in heel pain.   
• An increase in body weight combined with non-supportive shoes and an increase in the amount of standing and walking one does can result in heel pain.
• Going barefoot for long periods of time, wearing flat, unsupportive shoes, sandals, or flip flops with no arch support can also cause heel pain.
• Flexible feet and high arched feet are foot types that are particularly prone to the developement of heel pain.

How Do You Prevent Heel Pain?

• To prevent heel pain, avoid a sudden change in physical activity.
• If you are taking up a new sport, do some conditioning before "going for the gold". In other words, ease into your new sport gradually.
• It is also very important to wear the proper shoes. Two hours of aerobics or dancing in flat canvas sneakers can cause a lot of damage to the foot.
• Well-fitted running shoes will suffice for a number of sports and occupations, and are especially good for walking. Avoid going barefoot, avoid flat, unsupportive shoes, sandals, and flip flops.
• Finally, keep your weight under control and see your podiatrist if your heel pain does not respond the above suggestions.

How Is Heel Pain Treated?

         Self Care

• Medication: over the counter anti-inflammatory medications such as Advil, Nuprin, Aleve, and Motrin are effective in helping to alleviate this type of pain. It is important to take this kind of medication with food and discontinue using them if stomach upset or heartburn is noticed. If you have a stomach ulcer, you should not take this kind of medication.

• Change the type of shoe you wear: avoid wearing flat, unsupportive types of shoes such as flat sandals, Keds, deck shoes, and flip flops. Also, avoid going without shoes. A good type of shoe to wear as much as possible is an athletic type of shoe such as New Balance, Nike, Reebok, or any brand name walking shoe such as Rockport, Merrill, Foot Joy, or SAS. Surprisingly, most women notice less heel pain when wearing heels and men find relief when wearing cowboy boots. Adding an over-the-counter arch support may help alleviate some of the pain as well.

• Modifying your activity: This is perhaps the most important form of self treatment. Standing in one spot for long periods of time should be avoided. Sit as much as possible, and if you can, elevate your feet.
• Ice and stretching: You can do both stretching and icing of the plantar fascia by rolling the arch and heel of your foot over a frozen water bottle two to three times a day and after participating in physical activity or long periods of standing and walking.  Stretching the plantar fascia of your foot before getting out of bed in the morning is very effective in alleviating heel pain on the first few steps out of bed each morning. This can easily be done by pulling your toes toward your head with your leg fully extended (straight out) and holding this position for 30 seconds.   

• Cortisone Injections: Once the mainstay of treatment, cortisone injections are falling out of favor as a treatment for heel pain.  Research has shown that cortisone can weaken the plantar fascia resulting in rupture.  Most heel pain can be managed with orthotics alone. However, some heel spurs need additional treatment and if surgery is not possible, injections can be performed in selected cases.  Also, cortisone should not be injected more than three times in the same area in a lifetime due to its tendency to cause the fatty padding over the heel spur to shrink or atrophy. As a result, too many injections can actually make the pain worse.
• The Topaz Procedure: This is the latest advancement in the treatment of chronic heel pain that fails to respond to orthotics and other conservative treatments. The procedure involves inserting a treatment wand into the plantar fascia through small stab incisions on the bottom of the heel (this is called a percutaneous approach as opposed to an incisional approach).  The procedure is done under local anesthesia with IV sedation at a surgery center and not as an office procedure at this time.  An electrical current is applied to the treatment wand that causes an increase in blood supply, reduction in the thickening, and a dramatic decrease in pain in the plantar fasciitis.  After the Topaz procedure, most patients are able to return to shoes with orthotics in a week and to most all other activities in 3-4 weeks. It is necessary for patients to continue to wearing orthotics after the Topaz procedure in order to prevent recurrence of the condition and to prevent it happening in the other foot.
• Extracorporeal Shock Wave Therapy (ESWT):This another treatment for chronic heel pain. This non-surgical procedure uses high-energy shock waves to increase blood flow and stimulate healing of the plantar fascia. The machine that performs this treatment is similar to the Lithotriptor that is used to treat kidney stones. I no longer do this procedure since most insurance companies no longer cover it and the results have not been as good as the Topaz procedure.
  

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