Heel Pain
Heel Pain-Plantar Fasciitis
The Condition
Most people have heard of or know someone who was been told they have Heel Spurs. The condition of Heel Spurs is also called Plantar Fasciitis. It is probably the most common reason a person seeks treatment from a Foot Doctor. Heel spurs or Plantar Fasciitis is described by patients as being an intense stabbing pain felt in the bottom of the heel area, that is especially painful when first starting to walk after a period of rest. It’s is very common for people to say,
“When I get out of bed in the morning, I can hardly walk my heel hurts so bad…But after I take 15 or 20 steps the pain seems to ease up quite a bit.â€
The pain of Plantar Fasciitis commonly gets worse as the day goes on. Many people will describe two peaks in their pain, one occurring when they first get out of bed in the morning and the other as they continue to walk through their work day.
The Plantar Fascia is a broad flat band found on the bottom of the foot. The Fascia functions to resists flattening of the foot when weight is applied. So every time weight is placed on the foot the fascia is put under tension. Additionally, when the toes are bent upward, as they are with walking, the fascia is put under additional tension. This tension is most pronounced at the fascia main attachment point into the heel bone. Plantar Fasciitis is the state if the Plantar Fascia being inflamed.
The Cause
Plantar Fasciitis is primarily caused by overworking the foot. The repeated loading of the fascia through activity leads to micro-tears in the Fascia. Once the injury reaches the point beyond what can be repaired in a nights sleep, we begin to have pain in the area of the injury. In other words, our foot health is out of balance, with more injury occurring than repair.
Heel Spurs or Plantar Fasciitis can be initiated in almost an unlimited number of ways. Some common ways Plantar Fasciitis begins:
- Starting a walking or exercise program
- Taking a pet for walks
- Walking or standing for long periods of time at work
- Participating in a demanding sport
- Shopping for an extended period of time
- Working using a Ladder
- Working in the yard or on the lawn
Pretty much anything that has you walking or standing for extended periods of time could be the cause of Plantar Fasciitis starting. Whatever the cause, once the condition has started, it seems to take very little to keep it going. Plantar Fasciitis can really throw a wrench into your life making it very difficult to impossible to do what you want to do.
Traditional Conservative Treatments
Knowing that Plantar Fasciitis/Heel Spurs is caused by micro-tears to the fascia from over-working of the foot, the time tested treatment focuses on two main goals. The first is reducing injury to the foot and the second is the reduction of inflammation.
Reducing Injury
Reduction of injury to the Fascia can really only be done two ways. The first method is behavioral. You make a decision to reduce your activity level so the foot can rest more.This reduces injury to the Fascia and begins tipping the scale in the direction of more healing than injury, moving you toward recovery. Although this method typically works very well, it’s not practical for most people. We all have busy lives with lots of demands making slowing down to allow the foot to recover simply impossible.
The second way to reduce injury is to provide “stress shielding†to the foot. This is done primarily by using supportive shoes but could include the use of orthotics, Cam Walkers, casts or crutches. This is the way most people reduce injury to the Fascia as its still allows a person to be fairly active with minimal disruption with life.
Stretching exercises for lengthening the calf muscles is often recommended. Gaining a small degree of length in the calf muscle is believed to reduce tension on the fascia with each step taken thereby reducing injury to the Fascia.
Inflammation reduction
Inflammation is a direct consequence of the injury to the Fascia. The combination of the injury and the inflammation result in the pain experienced in Plantar Fasciitis.Once you have reduced the volume of stress injury to the Fascia efforts are directed toward inflammation reduction. There are a number of ways to reduce inflammation. Most of the time icing is recommend to help reduce inflammation. Anti-inflammatory medications such as Ibuprofen or Naproxen are often used in patients who can take them safely. Additionally, steroids are an integral part of the treatment of inflammation. Steroid can be given as a pill pack or injected. Plantar Fasciitis can be stubborn to treat and often times all three methods of reducing inflammation are used.
Physical Therapy, night splints and orthotics can be used. All are in my opinion second tier treatments, used only if the primary treatment fails.
Traditional Surgical Treatments
As stated previously, Plantar Fasciitis responds well to non-surgical treatment most of the time so surgery is performed in less than 10% of the cases. Surgery for Plantar Fasciitis usually consists of what is called a “release†of the fascia. This is essentially cutting the fascia near its point of attachment into the heel bone. This can be done with an small open incision or by using a small arthroscope.
Newest Treatments
Platelet Rich Plasma Injection
Platelet injections have been used for the treatment of Plantar Fasciitis for about 10 years now. The treatment consists of drawing blood from a patient’s arm and spinning the blood down to concentrate the platelets. The platelet concentrate is then injected into the area of the insertion of the plantar fascia. Often times 4-6 injections at 6 week intervals is done. This treatment has been shown to be benefit in some patients.
Shockwave
Shockwave treatment, also called extracorporeal shockwave therapy (ECWT) has been around for about 20 years now. The treatment consists of the use of ultrasound to incite an acute inflammatory reaction with subsequent dampening of inflammation. It is not unusual for 2 to 3 treatments to be needed.
Stem Cell Injections
Stem cell injection, also called micronized dehydrated human amnion/chorion membrane (dHACM), is an injection given into the area of peak pain following a shot to numb the area. Results have been promising showing marked reduction in pain following injection. The injection is believed to modulate inflammation and stimulate healing.
Common Course of the Condition
Plantar Fasciitis can be a rather stubborn condition to treat often taking anywhere from 4 weeks to 4 months to resolve. I have seen patients who have had the condition for decades, primarily because they never sought treatment. The time to improve really depends on how much demand a person has on their feet normally. If you are on feet a lot, you can expect it to take longer. Typically the condition gradually improves with treatment with occasional “blips†of worsening with those “blips†being tied to increases in activity.
Common Questions about the condition
Q: Don’t I need to have the spur removed to get better?
A: No. Most (more than 90%) cases of Plantar Fasciitis do not need surgery. It is rare to need to remove a “spur.†Heel Spurs are sometimes found in people who have Plantar Fasciitis but are generally not the cause of Plantar Fasciitis.
Q: I’m doing the same things I’ve always done, why do I have this now?
A: The exact event or stress that caused the heel pain isn’t always clear. In most cases however, the gradual slowing down in our ability to recovery and heal is often the explanation when activity levels haven’t really changed. Even though we’d like to, we simply can’t function at the same activity level forever.
Q: What are the best shoes for this problem?
A: There are no “Best Shoes†for this. The foot needs support and stress shielding. The forces that injure the foot are twisting, bending, compressing and impacting forces. Shoes need to reduce these forces. The shoes should be not bend easily and should be very resistant to twisting. The shoes should include a shock absorbing sole and a memory foam insole is helpful. In addition to protecting the foot from these forces the shoes must fit properly and be comfortable. Comfort is very subjective making recommending a specific shoe impossible. Any shoe, so long as its is comfortable and resistant to bending and twisting it should effectively reduce stresses on the feet.
Q: How about those “Custom Inserts†I see at the store where you step on a scanner?
A: Keep your money. They rarely help.
Q: If I get a cortisone injection, how long will it last?
A: There is no specific amount of time an injection will last. Steroid Injections work by reducing inflammation. Injections usually markedly reduce inflammation but may not completely eliminate it. After getting an injection it’s very important to protect the foot from overuse. Otherwise a new round of inflammation with begin, making it seem like the “shot†wore off.
I hope you found this informative and helpful. If you have further questions or need help in relieving your heel pain, call for an appointment today. We pride ourselves on getting our patients back to doing what they want to do or what they need to do as quickly as possible.