Heel pain is one of the most common causes of foot pain, among the many causes of heel pain, plantar fasciitis is probably the most common that we see. There are many causes of heel pain including trauma (no surprise there), inflammatory conditions (arthritis and non-rheumatoid arthritis), stress reactions, deformities and structural faults, long term consequences of old injuries, biomechanical issues (foot functional problems) and enthesopathies (pain where soft-tissues attach to bone). The most common cause we see is an enthesopathy called plantar fasciitis.
What is Plantar Fasciitis
Plantar Fasciitis is a painful condition at the bottom of the heel just in front of where the heel meets the ground. The Plantar Fascia is a very strong ligament that extends from the heel to the ball of the foot and attaches to the bottom of the toes in strong slips. Its job is to tether the heel and the ball of the foot together and help to support the arch. As we put weight on the foot the height of the arch drops and the ligament and muscles tighten, suspending the arch. When it gets damaged it usually occurs at the weakest part of the ligament which is where it attaches to the heel bone ( the ball of the foot is 4 Xs as wide). The ligament also shares fibers with the Achilles Tendon ( the strong tendon at the back of the heel that becomes the muscles of the calf). This usually occurs gradually and can last for years.
Symptoms of Plantar Fasciitis
Signs of Plantar Fasciitis are fairly consistent, pain after rest or getting up in the morning, increasing pain with activity and the sense that you are stepping on a rock or nail with tightness and a pulling in the arch of your foot. There is usually little to no swelling and no bruising. Pain is intermittent, from severe to mild and benefits from rest. Pressure on the heel itself is usually asymptomatic except at the attachment point. Long Term plantar fasciitis can cause the bone to react with spur formation which is simply a ledge across the origin of the ligament.
In the early stages the problem is inflammation of an otherwise healthy ligament, after 18-24 months the ligament becomes degenerative and doesn’t respond to the same treatments as it did earlier. Plantar fasciitis becomes plantar fasciosis. Now simple anti-inflammatory therapy won’t work, people become frustrated and the problem persists. These two issues have different treatment protocols.
Treatment for Heel Pain (Plantar Fasciitis)
Plantar fasciitis is treated from three different directions, dealing with the function of the ligament (biomechanical), addressing the strong effect of the pull of the Achilles Tendon, and attacking the inflammation and pain that the patient is experiencing.
At Home Treatment for Heel Pain
At home treatment should include modification of footwear and changes in barefoot habits. Patients should avoid flat shoes, barefooting and anything that doesn’t elevate the heel slightly. The second thing that should be done is gentle and frequent stretching of the Achilles Tendon (key is gentle and frequent) and finally dealing with the pain and inflammation (ice bottle rolls) and if there are no GI issues careful use of anti-inflammatory medicine.
Medical Treatment for Heel Pain
Treatment in the physician’s office often includes all of the above with recommendation of the use of running shoes with a soft elevated heel ( both in and out of the house), radiographs to rule out bone issues, appropriate use of diagnostic modalities and the use of inserts or orthotics if necessary, frequent gentle stretching. A referral to physical therapy if the calf simply won’t respond can be beneficial. Corticosteroid injection to reduce inflammation and to deal with pain is extremely helpful. Trying to stretch with a trigger point firing is extremely difficult. Good compliance in addressing all 3 of these (mechanical control, AT stretching and inflammatory control) usually results in upwards of 90% success.
Mechanical control is initially with shoe changes and avoidance of barefooting and avoidance of flats. If simple changes are unsuccessful, we will add sports inserts and if there is a significant mechanical issue or insert failure we move to functional orthotics. Inserts are simple buttresses for the arch, they serve to push up in the arch to slow pronation. A functional orthotic will address the faults in the foot by controlling how the foot hits the ground and how it adjusts to weight bearing. An orthotic uses the foot to help itself rather than be an arch bumper.
Advanced Treatment for Heel Pain
If the initial course of care fails we move forward with assurance of the diagnosis then more aggressive treatment. Other therapies include further biologic injections with PRP ( spun plasma to concentrate healing proteins) stem cell injections ( quite expensive), or moving to shockwave therapy ( EPATT) which triggers a healing immune response, MLS Laser therapy ( Biwave therapy pain and inflammation) or finally surgical release of the ligament ( partial including TENEX, instep release, Topaz) or complete release.
Plantar fasciosis is resistant to steroid injection as the ligament is becoming diseased not just inflamed. Patients that have had it for 2 years and fail steroid injection usually find that they have fasciosis rather than fasciitis. These patients move quickly into orthotics, EPATT or MLS laser therapy and finally if necessary surgery. MRI frequently shows a thickened ligament with an unhealthy signal.
Heel Pain Treatment in Omaha, NE
There isn’t a lack of treatment for heel pain, early aggressive therapy, changes in negative habits and disciplined patient compliance can often speed recovery. If you are struggling with heel pain try to address all three treatment modalities simultaneously, if that fails, the experts at Omaha Foot & Ankle Specialists can help. Call our office at 402-333-8856 or click here to make an appointment.