Heal Your Heels
by Jeffrey W. Watkins, DPM, AACFAS

It has been noted that heel pain can affect anyone between the ages of 8 and 80. In fact, a local news station has reported that some 30 million people in the United States suffer from heel pain. Heel pain can be caused by numerous factors including, but not limited to: arthritis, stress fractures, heel fat pad atrophy, nerve entrapment, trauma, bone or soft tissue tumors, or growth plate irritation in children. However, it is estimated that approximately 90 percent of all heel pain is caused by plantar fasciitis which is an inflammation of the plantar fascia.

The plantar fascia is a thick band of connective tissue (like leather) that attaches to the bottom of the heel bone (calcaneus) and extends the entire length of the foot, attaching to the soft tissue at the ball of the foot. Its function is to support the arch of the foot and help hold the structures of the foot together. Based on this function, it is easy to see how the fascia can become stretched and inflamed with activity. It is repetitive pulling of the plantar fascia at its attachment at the heel that causes the attachment site to become irritated and leads to the classic symptoms associated with plantar fasciitis.

Patients of all ages and sizes will report to the office with one very common complaint. Almost all will state, “My heel hurts!” They will then point to an area on the bottom/inside half of the heel as the focal point of the pain. Almost unanimously they will relate that the pain has gradually worsened over a period of time. Occasionally they may have endured an episode of trauma (jumping from a height or stepping on a rock or a toy). Patients will report having pain upon arising in the morning that will usually resolve or improve significantly after the first few steps of the day have been taken. They will then note pain when arising after any period of inactivity throughout the day, with that pain again improving after being up and about. By day’s end, there will be an aching, often throbbing, sensation in the bottom of the heel.

Evaluation discloses that there is a tenderness when pressure is applied to the bottom of the heel where the plantar fascia originates. Biomechanical examination is performed to evaluate the structure of the foot and the range of motion of both the foot and the ankle. The flat (pronated) foot is more susceptible to heel pain due to the increased flexibility of the foot with weight-bearing, which exaggerates the stretch on the plantar fascia. The high-arched (supinated) foot tends to have a more inherently tight fascia which can also lend itself to irritation. X-rays are often obtained to assure that there is no evidence of any bony abnormality or fracture, and this also allows for an assessment of the thickness of the heel fat pad. Often x-rays will show that there is a bone spur on the heel bone where the plantar fascia attaches. This spur simply indicates that there has been a chronic irrigation (at least 6 to 12 months) in this area caused by the repetitive pulling of the fascia on the attachment to the heel bone. The spur can also, however, often be found on x-rays of patients who have never experienced heel pain, and patients need to be assured that their pain can usually be controlled without having to remove the spur.

Treatment consists of controlling the causative factors. Initially patients are treated with stretching exercises and deep tissue exercises to be performed upon arising in the morning. These exercises make the first few steps of the day more tolerable. This can also be achieved with a night splint worn while sleeping that maintains the plantar fascia in a stretched position throughout the night. Plastic supportive arch supports in shoes will help control the stretching forces associated with weight-bearing and walking. Finally, application of ice for 20 to 30 minutes at the end of the day may help calm down the aching pain from the day’s activity. Often initially anti-inflammatory medications are not prescribed to aid in determining if the support and stretching are providing relief. Should relief not be adequate, additional treatment modalities can be recommended to decrease pain, allowing the patient to increase activity. Other treatment modalities may include any or all of the following: rest, anti-inflammatory medications, shoe modification, weight loss, custom-made orthotics, steroid injections, physical therapy, night splints, or immobilization.

If conservative treatment fails to provide complete relief, surgical transection of the plantar fascia with heel spur removal may be needed. This can be achieved via a traditional “open” surgical technique through a single 3 to 4-cm incision. Alternatively it can be performed by an Endoscopic Plantar Fasciotomy performed through two small stab incisions. Recently, there has been some interest in a procedure called Extracorporeal Shock Wave Therapy (ESWT). Like lithotripsy, which is used to break up kidney stones, this procedure bombards the painful heel with high-energy ultrasonic shock waves. ESWT has gained popularity due to its non-invasive nature with the promise of quick recovery. It should be noted, however, that few insurance companies presently cover the procedure.

Although plantar fasciitis is the most common cause of heel pain, there are other diagnoses that need to be ruled out. In children, the heel pain will most likely be due to inflammation of the growth plate of the heel (calcaneal apophysitis or Sever’s disease). Trauma can lead to a bone bruise of the heel. Significant increases in activities can result in calcaneal stress fractures, and traumatic ruptures of the plantar fascia can also occur. Tendinitis can develop within the muscles on the bottom of the foot. Nerve entrapment, foreign bodies, soft tissue masses, and arthritic conditions can all be possible causes of heel pain.

Heel pain is often a condition that requires ongoing comprehensive care to prevent future discomfort and achieve a lasting, effective result. Using a well-conceived treatment program can keep patients active and place them on the road to permanent recovery. With the help of a foot care specialist and some self diligence, you can, in fact, heal your heels.

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