Common Disorders
Heel Pain
Description
The most common form of heel pain, is pain on the bottom of the heel. It tends to occur for no apparent reason and is often worse when first placing weight on the foot. Patients often complain of pain the first thing in the morning or after getting up to stand after sitting. The pain can be a sharp, searing pain or present as a tearing feeling in the bottom of the heel. As the condition progresses there may be a throbbing pain after getting off your feet or there may be soreness that radiates up the back of the leg. Pain may also radiate into the arch of the foot.
To understand the cause of the pain one must understand the anatomy of the foot and some basic mechanics in the function of the foot. A thick ligament, called the plantar fascia, is attached into the bottom of the heel and fans out into the ball of the foot, attaching into the base of the toes. The plantar fascia is made of dense, fibrous connective tissue that will stretch very little. It acts something like a shock absorber. As the foot impacts the ground with each step, it flattens out lengthening the foot. This action pulls on the plantar fascia, which stretches slightly. When the heel comes off the ground the tension on the ligament is released. Anything that causes the foot to flatten excessively will cause the plantar fascia to stretch greater than it is accustom to doing. One consequence of this is the development of small tears where the ligament attaches into the heel bone. When these small tears occur, a very small amount of bleeding occurs and the tension of the plantar fascia on the heel bone causes a spur on the bottom of the heel to form. Pain experienced in the bottom of the heel is not produced by the presence of the spur. The pain is due to excessive tension of the plantar fascia as it tears from its attachment into the heel bone. Heel spur formation is secondary to the excessive pull of the plantar fascia where it attaches to the heel bone. Many people have heel spurs at the attachment of the plantar fascia without having any symptoms or pain. There are some less common causes of heel pain but they are relatively uncommon.
There are several factors that cause the foot to flatten and excessively stretching the plantar fascia. The primary factor is the structure of a joint complex below the ankle joint, called the subtalar joint. The movement of this joint complex causes the arch of the foot to flatten and to heighten. Flattening of the arch of the foot is termed pronation and heightening of the arch is called supination. If there is excessive pronation of the foot during walking and standing, the plantar fascia is strained. Over time, this will cause a weakening of the ligament where it attaches into the heel bone. When a person is at rest and off of their feet, the plantar fascia attempts to mend itself. Then, with the first few steps the fascia re-tears causing pain. Generally after the first few steps, the pain diminishes. This is why the heel pain tends to be worse the first few steps in the morning or after rest. Another cause of heel pain is compression of the calcaneal nerve and may be diagnosed thru neuro sensory motor testing.
One other factor that contributes to the flattening of the arch of the foot is tightness of the calf muscles. The calf muscle attaches into the foot by the achilles tendon into the back of the heel. When the calf muscle is tight it limits the movement of the ankle joint. When ankle joint motion is limited by the tightness of the calf muscle it forces the subtalar joint to pronate excessively. Excessive subtalar joint pronation can cause several different problems to occur in the foot. In this instance, it results in excessive tension of the plantar fascia. Tightness of the calf muscles can be a result of several different factors. Exercise, such as walking or jogging will cause the calf muscle to tighten. Inactivity or prolonged rest will also cause the calf muscle to tighten. Women who wear high heels and men who wear western style cowboy boots will, over time, develop tightness in the calf muscles.
Diagnosis
The diagnosis of heel pain and heel spurs is made by a through history of the course of the condition and by physical exam. Weight bearing x-rays are useful in determining if a heel spur is present and to rule out rare causes of heel pain such as a stress fracture of the heel bone, the presence of bone tumors or evidence of soft tissue damage caused by certain connective tissue disorders.
Treatment
Treatment of heel pain generally occurs in stages. At the earliest sign of heel pain, aggressive calf muscle stretching should be started. Additionally, taking an oral anti-inflammatory medication and over-the- counter arch supports or heel cushions may be beneficial.
The next phase of treatment might consist of continued calf muscle stretching exercises, cortisone injections and orthopedic taping of the foot to support the arch. If this treatment fails, or if there is reoccurrence of the heel pain, then functional foot orthotics might be considered. A functional orthotic is a device that is prescribed and fitted by your foot doctor, which fits in normal shoes like an arch support. Unlike an arch support, however the orthotic corrects abnormal pronation of the subtalar joint. Thus orthotics address the cause of the heel pain - abnormal pronation of the foot.
 The doctors at The Chesapeake Foot & Ankle Center, P.A are excited to also offer a new treatment, Extracorporeal Shock Wave Therapy, for chronic plantar fasciitis "heel pain". Extracorporeal" means "outside the body". Shock waves are created by very strong acoustic (sound) energy. Your ESW treatment will be performed with a device called the OssaTron. The OssaTron is a shock wave generator very similar to the shock wave devices used to treat kidney stones without surgery. The shock waves are created by a spark plus that is enclosed in a soft plastic dome filled with water. During ESW treatment, this dome is placed close against the heel so that the shock waves pass through the dome to the heel. ESW treatment has recently been found to be effective for treating chronic proximal plantar fasciitis.
NEW TREATMENT AVAILABLE
Introduction
Studies demonstrate that 15-20% of new patients seeking care by foot and ankle specialists complain of heel pain. Plantar fasciitis, heel spur syndrome, heel bursitis, nerve entrapment, stress fracture, gout, and systematic inflammatory conditions are just some of the possible causes. The vast majority (70-90%) if individuals diagnosed with heel spur syndrome / plantar fasciitis respond well to non-operative treatment. Until recently, the only remaining treatment option for those individuals that failed to improve was surgical intervention. Extra-corporeal Shock Wave Therapy (ESWT) now offers heel pain suffers new treatment options.
What is ESWT?
Extra-corporeal Shock Wave Therapy is a new non-invasive alternative to surgery. Similar technology has been used to successfully treat kidney stones since the 1980's. In this new application, shock waves are applied to the foot, aimed at the inflamed plantar fascia. Shock waves cause a "microtrauma" in the treated tissue that in turn triggers the body's own healing mechanism. Over stimulation of the pain transmitting nerves causes the release of enzymes that reduce pain. The tissue irritation that occurs further results in the ingrowth of new blood vessels to repair and heal the chronically irritated fascia.
What Happens During Treatment?
The entire treatment takes approximately 30-45 minutes. Our doctor will examine your foot and you will be asked to identify the area that presents the most pain. He/she will then proceed to numb your foot in preparation for treatment.
You will be asked to sit or lie on the examination table. The doctor will apply a gel to both your foot and therapy equipment. With ultrasound imaging, your doctor will visualize and measure the inflamed plantar fascia. Your foot will then be positioned on the shock wave head for shock wave therapy. You will hear small "snaps" that pick up in frequency as treatment is given. After treatment, you will be able to walk out of the treatment room.
Who Qualifies?
Generally, an individual who has failed to improve after six months of conservative management would be considered a suitable candidate. This includes stretching, shoe inserts / orthotic devices, cortisone injections, non-steroidal anti-inflammatory drugs, physical therapy, night splints, CAM walkers, weight loss, and rest.
What are the Expected Results?
A clinical study by Weil, Roukis and Weil et. al., The Journal of Foot and Ankle Surgery (Volume 41, No. 2) found that at an average 8.2 months following treatment, 82% of the patients treated with ESWT were very satisfied or satisfied. This compares with 83% of patients that had undergone surgical release of the fascia.
What about the Risks?
Adverse effects that have been reported seem to parallel the risks associated with the infiltration of local anesthetics, such as nerve injury or irritation, hematoma, bruising, and skin rash.
What is the Post Treatment Care?
Patients that have undergone ESWT may return to their pre-treatment level of function immediately following the procedure. That is, providing they are wearing supportive footgear, preferably in combination with orthotic devices / shoe inserts. Application of ice for the first few days may prove helpful. One may expect an increased level of discomfort three to seven days post-treatment as the local inflammatory response ensues. Athletic and strenuous weight bearing activities should be avoided for two to three weeks.
What are the Long Term Effects?
Sufferers of heel pain must consider their symptoms as a condition which should be managed by continued compliance with stretching, supportive footgear and avoidance of barefoot activities as well as positions which place excessive load on the forefoot (i.e. standing on ladders, squatting, walking uphill, etc.)
Fees / Insurance?
Many insurance companies and HMO's cover the cost of the procedure. Since ESWT is a new application for heel pain, some insurance companies have not yet developed payment guidelines. Your doctor will assist you in determining insurance coverage and your share of the financial obligation.
Summary
As with any treatment option there are no guarantees or assurances. No single treatment should be considered a panacea. Clinical studies have shown ESWT to be safe and effective in treating heel pain in individuals who have not responded to traditional conservative therapies such as stretching, shoe inserts / orthotic devices, cortisone injections, non-steroidal anti-inflammatory drugs, physical therapy, night splints, CAM walkers, weight loss, and rest. However, it appears that ESWT offers a clinical response similar to percutaneous plantar fascial release without the risks and loss of wages associated with surgery.
In the study by Weil et. al., patients reported improvement on the Visual Analogue Scale from 7.9 down to 3.1 at the 3 month follow-up.
This modality is FDA approved, and the treatment is performed in our Chesapeake Ambulatory Surgery Center. This procedure can be performed with local anesthesia only or IV sedation with local anesthesia.
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