the singing podiatrist.com

the foot stuff

heel pain

"... time wounds all heals."

Causes

By far, the most common cause of heel pain is plantar fasciitis - or inflammation of the plantar fascia, a wide swath of connective tissue running from heel to toes along the bottom of the foot. Repeated stress on the heel typically leads to micro-tears in the plantar fascia where it connects to the heel bone, resulting in inflammation and pain. As all sufferers of heel pain know, pain is usually worst when arising in the morning; a good half hour of hobbling about may be needed before it abates. Over night the fascia tightens because it is not being used. Inflammation sets in and when you take that first step you are forcing a tight fascia to stretch to its maximum. Pain often recurs after extended periods of standing, walking or running.

Some people are told they have heel spurs, or you may feel like a sharp piece of bone is jutting into the heel. If an x-ray were taken of the heel, some people with heel pain would have heel spurs and some people who don't have heel pain would have heel spurs. There is usually very poor correlation between heel pain and heel spurs. The spur, if it exists, is usually the result of the inflamed plantar fascia (the true cause of the pain) pulling on the heel bone.

Very rarely, heel pain can be caused by an arthritic or systemic medical problem. If the heel is hot, red and swollen or you have other joints that are hot, red or swollen, or you have other symptoms in your body associated with the heel pain, you should see your podiatrist or general practitioner to rule out these other causes.

A condition called tarsal tunnel syndrome can cause heel pain, but it is rare. The symptoms would likely include pain at the inside of the ankle and symptoms of numbness, tingling or burning into the bottom of the foot. Treatment is similar to that for plantar fasciitis.

Pain at the back of the heel is not plantar fasciitis. It is most likely achilles tendonitis or may be a condition called Haglund's Deformity, which is a bony bump that gets inflamed by chronic rubbing from shoes. These conditions are treated differently from plantar fasciitis. An accurate diagnosis by a podiatrist or other medical practitioner is essential.

Scenario

A podiatrist sees plantar fasciitis more often than any other foot complaint. Here are some typical scenarios where plantar fasciitis may occur: A 25 to 50 year old person of normal or greater than normal weight does one or some of the following:

Lets running shoes wear out.

Goes for an extra long walk or run (in some type of shoe they normally don't walk or run in)

Goes on a hiking trip (to Europe)

Works long hours either standing or walking.

Is under some level of increased stress (emotional, mental and/or physical)

Has changed their walking pattern (gait) because of pain somewhere else in the body.

The longer the symptoms go untreated, the longer it generally takes to alleviate the condition.
If you have been having a series of lower extremity symptoms, start thinking about the possibility that an underlying biomechanical problem is trying to get your attention.

Not everyone with plantar fasciitis has a pronation problem (collapsing arches) though many do; not everyone with a pronation problem will get plantar fasciitis, but they will likely have some pronation-related problems (plantar fasciitis, bunions, neuromas, knee pain, tendonitis, low back pain).

Treatment - try yourself

Give the foot a rest. Fasciitis is, after all, an overuse injury. If you've been running or walking further than usual, cut back to half your distance. Better yet, rest for a week or two, then come back slowly. If you've just started to get a tender spot, you may get over it in a few weeks. But if you've had pain for a while, don't expect miracles.

Try other forms of exercise. Simply varying your workout with a less foot-dependent sport might be all you need in the early stages of fasciitis. Swimming or cycling are excellent substitutes.

Massage the painful area with ice. This may help reduce inflammation. Once or twice a day for 20 minutes can be helpful.

Stretch your achilles tendon. The achilles tendon, which runs down the back of the leg inserts into the bottom of the heel, very close to where the plantar fascia originates. A relaxed calf muscle takes stress off the heel bone and can help considerably. Also, once you start walking around with a sore heel, you will most likely end up with a tight calf muscle (because you will use the calf muscle to relieve pressure on the heel.) In the long run, a tight calf muscle will lead to increased pronation which will make the heel pain worse. To stretch the calf muscle, lean against a wall, shoes off, toes pointed in and very gently lean into the wall until you feel a gentle pull on the calf muscle. Hold it for several minutes. Do the stretch midday and later in the day and after exercise. Never stretch by hanging the foot off a stair or pushing the ball of the foot against the wall. This will over stretch the calf muscle and cause further injury (although it may feel good at the time).

Wear shoes with good arch support and heel counter support. Running shoes, hikers and some walking shoes are excellent choices. You will probably have to spend over $100 to get a good quality shoe. Don't shortchange yourself. Stay in supportive shoes as much as possible, especially walking around the house.

Treatment - See a Podiatrist

Low dye taping - this taping reduces pronation which in turn relieves stress on the plantar fascia. Often, inflammation will reduce immediately and pain will subside. Some people can get better with a series of 6 or 8 weekly tapings. If the taping helps and the pain recurs every time the tape comes off, this is an indication that custom orthotics would be useful.

Custom Foot orthotics - Many people who get plantar fasciitis have an underlying pronation problem. The fact that plantar fasciitis occurred is your body's way of telling you that something needs to be done. The best thing to do is to address the cause of the problem, which in many cases is over-pronation. The only way to effectively control excess foot pronation is with properly made custom orthotics - made from sitting casts of the feet and by a professional lab. A podiatrist generally provides the most expertise in this area.

If you have orthotics that are not helping, either (1) they were not made properly for your feet and they need to be remade, or (2) they need modifications, or (3) some other type of treatment needs to be undertaken.

Some people who get plantar fasciitis do so because of an episode of overuse. This can occur on a long walk, with a new activity or with improper shoes. If there is no underlying pronation problem the symptoms will clear up quickly with a little rest. Orthotics are not necessary in this situation.

Shoe evaluation - Certain types of shoes can make plantar fasciitis worse. Even if your shoes feel comfortable it doesn't mean they're good for you. Generally, a very stable heel counter with a good arch support (unless you're wearing orthotics) and laces is preferable. If you have to dress up for work, certain types of shoes are better than others. Choosing the most effective shoe to wear can be very individual. If you are wearing orthotics to treat your plantar fasciitis, it is crucial that the orthotics fit and work properly in any shoes that you wear for standing or walking more than 30 minutes at a time.

Cortisone injection - As scary as it sounds, some people get immense relief with a steroid injection. This is usually reserved for people who are in intense pain and cannot walk, or people who have tried other conservative measures and had no relief. There is very little danger of side effects as the steroid is injected locally into the heel. It is important to rest the foot for the week following the injection.

Massage therapy - your podiatrist or doctor may recognize the potential benefits of professional massage therapy. It makes sense that if you have a chronically tight fascia, that any treatment that increases blood flow and gently stretches the fascia back to its normal length would be helpful. Most people have weekly sessons for 6 to 8 weeks and often have considerable improvement.

Complete non-weightbearing - if you're unlucky enough to have no response to any of these conservative treatment approaches, you may need to stay completely off your feet. This usually works for people who are extremely overworked and have to be forced to get off the foot. It can be done with a plaster cast and crutches or wheelchair for 3 to 5 weeks. This can be arranged through a podiatrist or at a cast clinic.

Surgery - is rarely necessary, but if nothing else works, look for a qualified podiatric surgeon in your community.

Other - I haven't listed other forms of treatment that some people may have tried, only the ones that I feel are relevant from my perspective and experience as a podiatrist.

Final note

Once you've had heel pain for a month or more you may start to get disheartened that the pain may never go away. How quickly it goes away will depend on how quickly you seek treatment and pursue the treatment options discussed above. Sometimes it requires some detective work to determine exactly what may be contributing to the problem and which treatment options will work for you. Be patient and if you're not getting results, talk to your podiatrist about your frustration. Physical pain can be emotionally draining and who's got time for it? Sometimes your body is simply trying to tell you to slow down.