Heel Pains
Overview
Heel pain is most often caused by plantar fasciitis, a condition that is sometimes also called heel spur syndrome when a spur is present. Heel Pain may also be due to other causes, such as a stress fracture, tendonitis, arthritis, nerve irritation, or rarely, a cyst. Because there are several potential causes, it is important to have heel pain properly diagnosed. A foot and ankle surgeon is able to distinguish between all the possibilities and determine the underlying source of your heel pain.
Causes
There are two different categories of heel pain. The first is caused by over-use repetitive stress which refers to a soreness resulting from too much impact on a specific area of the foot. This condition, often referred to as "heel pain syndrome," can be caused by shoes with heels that are too low, a thinned out fat pad in the heel area, or from a sudden increase in activity. Plantar fasciitis, a very common diagnosis of heel pain, is usually caused from a biomechancial problem, such as over-pronation (flat feet). The plantar fascia is a broad band of fibrous tissue that runs along the bottom surface of the foot, from the heel through the midfoot and into the forefoot. Over-pronation can cause the plantar fascia to be excessively stretched and inflamed, resulting in pain in the heel and arch areas of the foot. Often the pain will be most intense first thing in the morning or after a prolonged period of rest. The pain will gradually subside as the day progresses.
Symptoms
Usually worse with the first few steps in the morning or at the initial point of activity. The latter usually gets better with continued activity (squeaky hinge analogy). Walking, running, sprinting, hill running and jumping will increase the pain. Often, the natural response is to walk on the outside of the foot - in supination - to lessen the stress on the plantar fascia - resulting in new problems.
Diagnosis
A biomechanical exam by your podiatrist will help reveal these abnormalities and in turn resolve the cause of plantar fasciitis. By addressing this cause, the patient can be offered a podiatric long-term solution to his problem.
Non Surgical Treatment
Treatment for plantar fasciitis should be directed at resting the plantar fascia, providing support for the arch area and limiting pronation. This is often accomplished with the use of supportive strapping with athletic tape, arch supports and orthotics. Heel lifts may also be helpful. Anti-inflammatories, pills as well as cortisone injections, may be effective as an adjunctive treatment by speeding up the reduction of inflammation. However, if used alone, anti-inflammatories rarely lead to resolution of the condition. Stretching exercises, physical therapy and night splints may also be helpful. The majority of cases respond to non-surgical treatment although it may take several weeks to reach a comfortable level. In those cases that do not respond adequately to conservative measures, surgical release of the plantar fascia may be considered. However, a new non-surgical treatment called Extracorporeal Shockwave Therapy (ESWT) is now available as an option for recalcitrant plantar fasciitis. ESWT was approved by the FDA recently for the treatment of chronic heel pain. It has been in use for several years on thousands of patients in Europe and has been successfully used to restore patients with chronic plantar fasciitis to a normal, active lifestyle. ESWT is a non-invasive procedure that uses high intensity sound waves similar to what is routinely used to treat kidney stones. The treatment is usually performed in the office or in an outpatient surgical center. The procedure is performed under local anesthesia and takes about 25 minutes. The shockwaves are directed at the plantar fascia and stimulate an inflammatory healing response.
Surgical Treatment
If treatment hasn't worked and you still have painful symptoms after a year, your GP may refer you to either an orthopaedic surgeon, a surgeon who specialises in surgery that involves bones, muscles and joints or a podiatric surgeon, a podiatrist who specialises in foot surgery. Surgery is sometimes recommended for professional athletes and other sportspeople whose heel pain is adversely affecting their career. Plantar release surgery is the most widely used type of surgery for heel pain. The surgeon will cut the fascia to release it from your heel bone and reduce the tension in your plantar fascia. This should reduce any inflammation and relieve your painful symptoms. Surgery can be performed either as open surgery, where the section of the plantar fascia is released by making a cut into your heel or endoscopic or minimal incision surgery - where a smaller incision is made and special instruments are inserted through the incision to gain access to the plantar fascia. Endoscopic or minimal incision surgery has a quicker recovery time, so you will be able to walk normally much sooner (almost immediately), compared with two to three weeks for open surgery. A disadvantage of endoscopic surgery is that it requires both a specially trained surgical team and specialised equipment, so you may have to wait longer for treatment than if you were to choose open surgery. Endoscopic surgery also carries a higher risk of damaging nearby nerves, which could result in symptoms such as numbness, tingling or some loss of movement in your foot. As with all surgery, plantar release carries the risk of causing complications such as infection, nerve damage and a worsening of your symptoms after surgery (although this is rare). You should discuss the advantages and disadvantages of both techniques with your surgical team.
Prevention
Make sure you wear appropriate supportive shoes. Don't over-train in sports. Make sure you warm up, cool down and undertake an exercise regime that helps maintain flexibility. Manage your weight, obesity is a factor in causing plantar fasciitis. Avoid walking and running on hard surfaces if you are prone to pain. You should follow the recognized management protocol "RICED" rest, ice, compression, elevation and diagnosis. Rest, keep off the injured ankle as much as possible. Ice, applied for 20 minutes at a time every hour as long as swelling persists. Compression, support the ankle and foot with a firmly (not tightly) wrapped elastic bandage. Elevation, keep foot above heart level to minimize bruising and swelling. Diagnosis. Consult a medical professional (such as a Podiatrist or doctor) especially if you are worried about the injury, or if the pain or swelling gets worse. If the pain or swelling has not gone down significantly within 48 hours, also seek treatment. An accurate diagnosis is essential for proper rehabilitation of moderate to severe injuries.
Heel pain is most often caused by plantar fasciitis, a condition that is sometimes also called heel spur syndrome when a spur is present. Heel Pain may also be due to other causes, such as a stress fracture, tendonitis, arthritis, nerve irritation, or rarely, a cyst. Because there are several potential causes, it is important to have heel pain properly diagnosed. A foot and ankle surgeon is able to distinguish between all the possibilities and determine the underlying source of your heel pain.
Causes
There are two different categories of heel pain. The first is caused by over-use repetitive stress which refers to a soreness resulting from too much impact on a specific area of the foot. This condition, often referred to as "heel pain syndrome," can be caused by shoes with heels that are too low, a thinned out fat pad in the heel area, or from a sudden increase in activity. Plantar fasciitis, a very common diagnosis of heel pain, is usually caused from a biomechancial problem, such as over-pronation (flat feet). The plantar fascia is a broad band of fibrous tissue that runs along the bottom surface of the foot, from the heel through the midfoot and into the forefoot. Over-pronation can cause the plantar fascia to be excessively stretched and inflamed, resulting in pain in the heel and arch areas of the foot. Often the pain will be most intense first thing in the morning or after a prolonged period of rest. The pain will gradually subside as the day progresses.
Symptoms
Usually worse with the first few steps in the morning or at the initial point of activity. The latter usually gets better with continued activity (squeaky hinge analogy). Walking, running, sprinting, hill running and jumping will increase the pain. Often, the natural response is to walk on the outside of the foot - in supination - to lessen the stress on the plantar fascia - resulting in new problems.
Diagnosis
A biomechanical exam by your podiatrist will help reveal these abnormalities and in turn resolve the cause of plantar fasciitis. By addressing this cause, the patient can be offered a podiatric long-term solution to his problem.
Non Surgical Treatment
Treatment for plantar fasciitis should be directed at resting the plantar fascia, providing support for the arch area and limiting pronation. This is often accomplished with the use of supportive strapping with athletic tape, arch supports and orthotics. Heel lifts may also be helpful. Anti-inflammatories, pills as well as cortisone injections, may be effective as an adjunctive treatment by speeding up the reduction of inflammation. However, if used alone, anti-inflammatories rarely lead to resolution of the condition. Stretching exercises, physical therapy and night splints may also be helpful. The majority of cases respond to non-surgical treatment although it may take several weeks to reach a comfortable level. In those cases that do not respond adequately to conservative measures, surgical release of the plantar fascia may be considered. However, a new non-surgical treatment called Extracorporeal Shockwave Therapy (ESWT) is now available as an option for recalcitrant plantar fasciitis. ESWT was approved by the FDA recently for the treatment of chronic heel pain. It has been in use for several years on thousands of patients in Europe and has been successfully used to restore patients with chronic plantar fasciitis to a normal, active lifestyle. ESWT is a non-invasive procedure that uses high intensity sound waves similar to what is routinely used to treat kidney stones. The treatment is usually performed in the office or in an outpatient surgical center. The procedure is performed under local anesthesia and takes about 25 minutes. The shockwaves are directed at the plantar fascia and stimulate an inflammatory healing response.
Surgical Treatment
If treatment hasn't worked and you still have painful symptoms after a year, your GP may refer you to either an orthopaedic surgeon, a surgeon who specialises in surgery that involves bones, muscles and joints or a podiatric surgeon, a podiatrist who specialises in foot surgery. Surgery is sometimes recommended for professional athletes and other sportspeople whose heel pain is adversely affecting their career. Plantar release surgery is the most widely used type of surgery for heel pain. The surgeon will cut the fascia to release it from your heel bone and reduce the tension in your plantar fascia. This should reduce any inflammation and relieve your painful symptoms. Surgery can be performed either as open surgery, where the section of the plantar fascia is released by making a cut into your heel or endoscopic or minimal incision surgery - where a smaller incision is made and special instruments are inserted through the incision to gain access to the plantar fascia. Endoscopic or minimal incision surgery has a quicker recovery time, so you will be able to walk normally much sooner (almost immediately), compared with two to three weeks for open surgery. A disadvantage of endoscopic surgery is that it requires both a specially trained surgical team and specialised equipment, so you may have to wait longer for treatment than if you were to choose open surgery. Endoscopic surgery also carries a higher risk of damaging nearby nerves, which could result in symptoms such as numbness, tingling or some loss of movement in your foot. As with all surgery, plantar release carries the risk of causing complications such as infection, nerve damage and a worsening of your symptoms after surgery (although this is rare). You should discuss the advantages and disadvantages of both techniques with your surgical team.
Prevention
Make sure you wear appropriate supportive shoes. Don't over-train in sports. Make sure you warm up, cool down and undertake an exercise regime that helps maintain flexibility. Manage your weight, obesity is a factor in causing plantar fasciitis. Avoid walking and running on hard surfaces if you are prone to pain. You should follow the recognized management protocol "RICED" rest, ice, compression, elevation and diagnosis. Rest, keep off the injured ankle as much as possible. Ice, applied for 20 minutes at a time every hour as long as swelling persists. Compression, support the ankle and foot with a firmly (not tightly) wrapped elastic bandage. Elevation, keep foot above heart level to minimize bruising and swelling. Diagnosis. Consult a medical professional (such as a Podiatrist or doctor) especially if you are worried about the injury, or if the pain or swelling gets worse. If the pain or swelling has not gone down significantly within 48 hours, also seek treatment. An accurate diagnosis is essential for proper rehabilitation of moderate to severe injuries.
