WHAT'S THE PROBLEM?
A pain has developed at the bottom of the heel, and it has gotten worse. The patient was not aware of having had any injury that caused it.

HOW DOES IT FEEL?
It feels like a dull ache most of the time, but when the patient first gets out of the bed in the morning, or when getting up after sitting for a period of time during the day, the pain in the heel is impressive. It almost feels like the heel has been bruised, from falling on a rock barefoot, but it is worse.

LET'S DO A TEST!
Since there are several causes for heel pain, we need to pin-point the exact location of the pain is in order to diagnose the basic underlying cause for the problem. Testing is simple and generally pain-free. It's important to find out WHERE it hurts, not just HOW MUCH it hurts. After excluding general medical conditions that might cause the condition, the exam is localized to the heel and surrounding structures. The important anatomical structures are the heel bone (calcaneus), the tissues that attach to the bottom of the heel (plantar fascia) and the nerves that pass from the leg into the bottom of the foot (posterior tibial nerve and its branches). The exam begins with an assessment of the blood vessels and nerves that end in the foot because blood and nerve supply affect treatment.



Palpation of arteries to assess pulses
Dorsalis Pedis above
Posterior Tibialis below



Examination of the plantar fascia
Thereafter, we work back to the area where the fascia attaches to the bottom of the heel.



Palpation of the point where the plantar fascia attaches to the heel bone
It is a good idea to tell patients to expect some discomfort as we palpate the heel bone, but that we are not going to push harder then necessary. Last, we feel the area over the side of the ankle where the nerves pass into the foot to rule-out nerve compression as the source of the problem.



Palpation of the nerve on the side of the ankle
In the process of this portion of the exam, it is important to maintain pressure over the nerve for about 30 seconds in order to simulate the kind of progressive compressive force that irritates the nerve enough to radiate to the bottom of the heel. During the exam, a positive test occurs when the patient reports experiencing pain. Finally, we will do a radiographic examination of the feet using an X-ray machine looking for evidence of abnormal bone growths.



Radiograph of bone spur, with bone spur, and with spurs at the back of the heel.
In some instances we might need to follow-up with an MRI to better display abnormal soft tissue or bone growths. In some instances we may want to evaluate the conduction of nerve impulses that course through the nerves into the foot.

HOW DID THIS HAPPEN?
There is a tight ligament (band of fibrous tissue) that stretches across the arch, from the ball of the foot to the heel bone, called the Plantar Fascia. When we walk, our feet have a tendency to roll inward, toward each other, in a motion that we call pronation. When feet pronate, they flatten, stretch out and the arch elongates. This causes excessive pulling on the Plantar Fascia ligament and attachment of the ligament to the heel bone begins to separate. An injury occurs where the ligament progressively tears off of the heel, fiber by fiber. Bleeding occurs next to the bone and inflammatory fluids accumulate between the ligament and the bone, forming a Bursitis, or fluid-filled sack. Over time, the body lays down scar tissue, in an attempt to "glue" the detached ligament fibers back on to the bottom of the heel bone. Over the course of 3-5 years, the scar tissue calcifies, and this calcium deposit eventually becomes visible on X-Ray as the Heel Spur. This inflammation of this Plantar fascia ligament is called Plantar Fasciitis, and in addition to the Bursitis, is what causes the pain. The bone spur itself has no nerve endings and doesn't hurt. It is just an associated finding that tells us that the inflammatory process, the Bursitis and Plantar Fasciitis have been present for a long time.

       

There are several reasons that this chronic injury can occur. Recent weight gain and increased activity level often start an episode. A person who has been mostly sedentary, who walks a lot at Disney World for 3 days is a prime candidate. A change of shoes from well supporting walking or athletic shoes to floppy sandals can do it. When the arch of the foot collapses or flattens, the Plantar Fascia is stretched, causing the injury where it attaches to the heel bone. Finally, conditions which cause generalized increased inflammation, like osteoarthritis or rheumatoid arthritis can cause this.

There is one more, smaller category of patients, who have heel pain due solely due to a loss of the protective fat pad cushion on the bottom of the heel. We rely on the Heel Fat Pad, that marvelous structure, to cushion our heel, like the sole of a good running shoe does, from the impact that a modern human body makes when it lands on it. All tissues atrophy or thin as we get older, giving many seniors their "drawn" appearance. The thinned Heel Fat Pad permits bruising, as our body weight is born by a much smaller, bony-hard and more concentrated area.

WHAT CAN I DO FOR IT?
It is better to rest the heel as much as practicable. When you are off your feet, the injury is healing and getting better. When you are standing, without any foot support, the heel is getting injured further. When you are standing when wearing orthotics (foot supports) and well supportive shoes, the injury decreases dramatically, but usually is not eliminated altogether. So, during the treatment period, if you have the choice of sitting or standing, sit ! If there are no health reasons to avoid them, a week's use of an over-the-counter anti-inflammatory medication may eliminate the pain.

WHAT WILL MY DOCTOR DO FOR IT?
First, we need to protect the bone from the pulling of the plantar fascia. We do this by using some kind of in-shoe arch supporting device - an orthotic. They come in pairs, one for each foot.

Orthotics (foot supports)

Next, we encourage the patient to stretch the tissue on the bottom of the foot. Three times a day, sit erect with the legs extended and loop a belt, scarf or towel around the forefoot. Pull the forefoot toward the upper leg. Expect to feel a mild pulling sensation at the back of the leg and in the arch. Stretching should not be done to the point of pain. This position is held for 30 seconds, and is repeated 3 times. The 3 repetitions at 30 seconds, 3 times-a-day is easy to remember.

Demonstration of stretching exercise.
Because of the risk of stomach upset, non-cortisone anti-inflammatory medication can only be used for some patients and only for about one week. With a good response to the medication, it is a good idea to taper off over the next several days so as to avoid an abrupt rebound of pain.
In addition to the above, we begin an aggressive course of physical therapy and cortisone injections. For physical therapy, the doctor may employ ultrasound, galvanic stimulation or any of a number of anti-inflammatory modalities in the office or at the offices of a physical therapist. The most effective way for physical therapy to work is if it is applied regularly, at least three times a week.

Photo of physiotherapy

Cortisone injections are usually done at weekly intervals, and most cases require 1-3 injections. The skin can be desensitized before the injection with a cold freezing spray designed to provide brief anesthesia. The injection is done from the inner side of the heel, not from the bottom.
It is helpful to strap the arch with tape combined with an arch pad. This serves as a temporary simulation of the support that an Orthotic will provide on a more permanent basis.
These measures will eliminate the problem in about 85% of patients within 3 weeks. Some get better quickly, others take the full 3 weeks. Surgery becomes necessary for the few who do not benefit from treatment. If the problem is due only to the inflamed fascia, the easiest procedure involves lengthening the fascia near the heel. The procedure is often done endoscopically today, through tiny incisions, using a small television camera inside the heel, very much like most knee surgery is done. Recovery is rapid and the success rate is better than 90%. If there is evidence that the nerve is being compressed at the side of the heel, we relieve the pressure by surgically freeing the tissue over the nerve. Heel spur removal is done only in the rare instance where the bony projection is directed downwards. For that smaller group of patients who've gotten their heel pain from a thinned Heel Fat Pad, a very effective treatment lies in a maximally cushioned and padded Orthotic, or other forms of padding. Wearing a good running shoe is a good start.

CAN I PREVENT FROM IT HAPPENING AGAIN?
Recurrence is rare after treatment, if the patient continues to employ good mechanical foot control by continuing to wear orthotics and good supportive walking or athletic shoes.

Author: Phil Organ, DPM

LINKS TO MORE INFORMATION

American Podiatric Medical Association - Heel Pain

American College of Foot and Ankle Surgeons - Heel Pain

SOAR Medicine Associates - Heel Spur

The Rothman Institute at Jefferson - Heel Pain

Independent Internet Research - Heel Spurs, plantar fasciitis, heel pain

Foot & Leg Center of Mid-Georgia -Heel Spur Syndrome

Foot & Leg Center of Mid Georgia - Endoscopic Plantar Fasciotomy

North Shore Podiatry Foot Care Center - Heel Spur/Plantar Fasciitis

North Shore Podiatry Foot Care Center - Endoscopic Plantar Fasciotomy (EPF)

Steven L. Barrett, DPM - Endoscopic Plantar Fasciotomy

Dr. Michael J. Marcus Heel Spur Syndrome

Drs. Hale & Huppin - Causes and Treatment of Heel and Arch Pain

Dr. Pribut on Heel Pain