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Dr. Thomas F. Bembynista
Heel Pain
Pain in the heel is one of the most common forms of foot pain in the United States. It can largely be attributed to the stress on the feet caused by daily activities and exercise that magnifies misalignments in the feet. Physicians use the terms plantar fasciitis and heel spur interchangeably to refer to heel pain.
There are many structures attached to the heel bone (calcaneus). The two structures primarily associated with heel pain are the plantar fascia band of connective tissue along the bottom of the foot that supports the arch) and the plantar muscles. Typically, in walking, the arch starts to flatten as the foot absorbs the weight of the body and these structures maintain the arch and stabilize the foot. Normally, they accomplish this effortlessly. Excessive exercise and occupations that require people to spend a lot of time on their feet may stretch these structures beyond their limits. This stretching can lead to muscle tears and bone spurs. Bone spurs on the heel occur when plantar fascia tension pulls a piece of bone away from the calcaneus. A bone spur usually appears on x-ray as a fishhook-shaped structure. This sharp-edged deformity irritates the nerves in the heel and, combined with the strained muscles, causes heel pain. Poorly fitted shoes exacerbate the problem further. Many people who work all day in new or ill-fitting shoes experience heel pain the next day. Ill-fitting running shoes may cause pain for weeks after a single run, as can playing 18 holes in improper golf shoes. This does not mean that a $100 pair of sneakers is necessarily better than a pair that costs $50; the fit is what is important. Sneakers and athletic shoes should fit properly, have plenty of cushioning to absorb shock, and provide support. There are different types of shoes for different sports. This is more than a marketing gimmick. Certain sports, such as tennis, require shoes that provide lateral support and others, such as cross-training, require shoes with a softer sole that conforms to irregular terrain. Another cause of heel pain is not warming up before exercise. The feet should be stretched by performing heel raises. Stand next to a wall flat-footed and raise the heels so all of the body weight is on the front of the feet and the toes. Then relax and return the heels to the ground. Repeat this procedure 10 to 15 times before exercising to stretch the foot muscles and prevent overstraining. Plantar fasciitis causes heel pain early in the morning that subsides as the day goes on. This occurs because the fascia is tight in the morning, accentuating the strain on the flexor muscle and, if present, bone spurs. As the day progresses, the muscles stretch and the pain subsides.
Heel spurs are usually an inflammation at the insertion of the plantar fascia (connective tissue on the sole of the foot that supports the arch) into the heel bone, causing heel pain. This condition can be treated successfully using a conservative approach in more than 95% of cases. Diagnosis includes a physical examination and an x-ray. When plantar fasciitis is indicated, heel pain is reduced by administering trigger point injections of a mild steroid into the side of the heel with a cold spray to numb the skin which significantly reduces pain from the injection. Trigger points are areas of painful tissue in and around muscles and fascia. Treatment typically requires 1 to 3 office visits to administer the injections.
After each injection, the arch is wrapped with self-adhering tape to provide support and the patient rewraps the arch daily. When long-term arch support is required, a custom arch support (orthotic) is constructed from a flexible plastic material. The orthotic is made using a model of the patient's foot and can be made to fit both dress and gym shoes.
If heel pain is intolerable or persists after conservative treatment, the new shockwave therapy can be used to treat the problem. Shockwave therapy is performed in the office under a local anesthetic. Surgery to remove the bone spur (if present) or release the plantar fascia may also be considered. After surgery, an orthotic is usually necessary and the foot must be monitored for changes.
Prevention is important because once symptoms develop, treatment often necessitates weeks or months of recuperation. To prevent heel pain, wear shoes that provide proper support. People who wear dress shoes often should invest in a pair that gives adequate support. Brand names and high prices do not guarantee a proper fit. A quality dress shoe should not bend easily in the midfoot at the arch. If it does, it will not provide enough support to maintain the arch when walking. Most work boots offer good support and have strong arches and well-cushioned heels. Heavily worn work boots may develop patterns on the sole that produce imbalances and detract from their effectiveness. Once a shoe of any type shows noticeable angulation in the heel, it should be replaced. The shoe may cause the foot to land awkwardly and problems can develop.
Overview This is a condensed version of an original article on heel pain from podiatrychannel.
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Dr. Thomas F. Bembynista
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