The Most Common Foot Problem : Heel Pain. (Heel Spurs, Plantar Fasciitis)

    The Most Common Foot Problem : Heel Pain. (Heel Spurs, Plantar Fasciitis)

  What's the most common foot problem that walks into my office?  What is the most common problem my friends, neighbors, employees, and yes even strangers as ask me about?  Without question its Heel Pain. It's so common that its seems the question isn't if you'll experience it, but when.  It's so common that my daughters are no longer phased by the sight of  one of my friends sprawled out in my family room getting an injection in their heel.  There are various conditions that can cause heel pain but 90% of the time its due to Plantar Fasciitis commonly called Heel Spur Syndrome, or Heel Spurs.

                                                     HEEL SPUR????????

     First Let's start with the name.  Although Heel Spur is the commonly accepted name for the condition its a misnomer.  The more accurate and correct name is Plantar Fasciitis.   The pain associated with the condition is due to an inflammation or irritation of the Plantar Fascial ligament .  The ligament is a thick band like structure which runs from the bottom of your heel to the ball of of your foot(fig. 1).

(fig.1) The ligament is stretched at its attachment to the heel with walking and standing

     When you stand and walk the ligament is stretched and elongated.  If the ligament is overstretched or irritated it becomes inflamed and painful (fig.1).  This usually occurs where the ligament attaches to the heel bone at the bottom of the heel.  This is also the location where some people will develop a small bony projection off the bottom of their heel called a spur (fig 2).  The spur may develop due to chronic tension of the ligament as it pulls at its attachment to the bottom of the heel bone. The spur does not cause the pain.  Its not a cases of you walking on the spur that's causing the pain. The spur projects forward toward the toes, not downward to the ground. The pain is due to the ligament becoming inflamed where its pulling on the heel bone at its attachment.  Frequently patients with severe pain will have no spur on x-ray and conversely patients will have huge bony spurs projecting off their heel and have no pain.

(fig.2) Heel spur projects forward not down

 
     Pain after resting or sitting is one of the hallmark symptoms of the condition.  This occurs because when you sit or sleep the foot is in a relaxed position and the foot is effectively pointed in a downward position.  This relaxes and takes tension off the Plantar Fascial ligament, the muscle group in the back of you leg and the Achilles tendon.  The ligament and the tendon get used to the relaxed position.  When you stand and put weight on your feet the ligament and the tendon are  put under sudden stretch and there is sudden pressure on the heel.  This is when you may feel severe sharp piercing pain.  Typically the pain beings to improve after you've been on your feet and walking for a period of time.


Hallmark Symptoms of Plantar Fasciitis / Heel Spurs.

1. Pain at the bottom central or bottom inside portion of your heel
2. Pain in the morning with first steps
3. Pain with standing/walking after sitting or rest
4. Pain with prolonged periods of standing walking
5. Increased Pain with walking barefoot or on hard surfaces
6. Burning pain or numbness of the bottom or inside of heel

So...you have heel pain.  Your symptoms mimic some or all of those above.  You have Fasciitis. Right?  Probably.  Chances are about 90% that you have Fasciitis.  However some conditions such as nerve entrapment, bone tumors, soft tissue masses, arthritic conditions, and trauma can cause similar symptoms so if symptoms do not improve, or get worse over several days, a visit to the Podiatrist is in order.

What Causes Plantar Faciitis???
Plantar fasciitis occurs when the plantar fascial ligament becomes inflamed or irritated.  The inflammation of the ligament causes pain.  So the real question is what causes the the ligament to become inflamed?...The list is endless;  Standing on hard surfaces, standing for prolonged periods of time, shoes with poor stability(especially sandals, flip flops), shoes with poor arch support, Weight gain,  increase in activity, decrease in activity, direct pressure to the ligament(i.e. standing on rungs of a ladder), activities that stretch the ligament...and the list go on!  What caused the ligament to become painful is not what's important.  What is important is what we need to do to resolve the pain.
 
The good news is that about 80-90 % of the patients that I see have their pain resolve.    Remember that this is a condition that did not begin suddenly.  Even if you notice the symptoms suddenly it is has been developing over time, so you shouldn't expect it to resolve suddenly. 

This is an extremely treatable condition and many of the measures that are used to treat this can be done at home once you begin to have symptoms.  Follow the suggestion below to begin treating your heel pain immediately, even if you plan on seeing the doctor.  The earlier you begin treatment the better the chances are at resolving the pain.  

There are three main components to treating heel pain: 
1) Reduce inflation of the Plantar Fascial Ligament
2) Support the Plantar Fascial Ligament
3) Stretch the ligament and tendons

 Here is what to do if you have heel pain:

1) REDUCE INFLATION:  

      Over the counter anti-inflammatory medication such as Motrin or Alieve should be started. For people who can tolerate these medicines,Tylenol can be taken.  Tylenol is not an anti-inflammatory medicine and won't be as effective.  Ice and Ice Massage is effective at reducing inflammation, 20 minutes on then 20 minutes off the area of pain.
( Ice massage- Freeze a bottle of water and use it like a rolling pin under the heel to massage and cool the area of pain)  If you don't massage the heel with ice just applying a bag of ice (20 min on 20 min off) is also very effective.

2) SUPPORT THE LIGAMENT:

       Supporting the ligament means supporting the arch of the foot.  A good quality athletic sneaker should be used.  This sneaker should have a removable insole so a better, more supportive arch support can be used in its place. Arch supports provide more substantial support of the Plantar Fascial and are extremely effective at reducing pain and keeping it away.

3) STRETCH THE LIGAMENTS AND TENDONS:

      Stretch the muscles/tendons of the back of the leg.  The Achilles Tendon and the Ham Strings.(fig. 3)  Stretching is Boring and it doesn't seems like its doing anything but it essential and it works!!!  Stretch a minimum of three times a day and before and after any sport activities including walking.  The use of a "night splint" is also an effective way to keep the ligament stretched while your sleeping or sitting. (see product recommendations below)  Stretching is key to treating this so stretch, stretch, and stretch...and when you think you've stretched enough stretch more.  Stretching is boring!  It may not seem like its having any effect and that your wasting time.  But it works!!!  Stretching is the simplest and most effective thing you can do.  So just do it !
   Check out this video for stretching the muscles in the back of you leg if you need to see how to stretch.

Achilles Tendon / Hamstring stretches.  Do 3 sets of 10,  3 times per day.  Click to see video:
http://www.youtube.com/watch?v=xI0tT0dY95E

 This video show how to stretch the Plantar fascial ligament in the bottom of the foot.
if you having pain when you stretch than you stretching too hard.

Platar Fascial Ligament stretch.  Do it 3 sets of 10, 3 times a day.  Click to see video:
http://www.youtube.com/watch?v=rxu433AIb7Y

These measure are extremely effective at treating the condition when done consistently.  So stick with them and if you don't feel better see the doctor for treatments you can't do at home.  The Podiatrist can provide prescription medicine, injections, physical therapy, x-rays/MRI's etc.  
     Most importantly the Podiatrist can make sure that it is Fasciitis and not some other condition that mimics the symptoms and may be more serious.


Let's talk about heel spur injections.  These injections are a mixture of steroids and local  anesthetics which are highly effective at reducing inflammation.  The class of steroids used in the injection are the type that reduce inflammation not the type that build muscle.  They are extremely safe when used sparingly.  Most podiatrist will limit the injections to about three per year.  If multiple steroid injections are given over a short period of time, detrimental effects can be seen.  In the case of multiple injections the steroid can begin to atrophy or shrink the protective fat pad at the bottom of the heel. It can  also effect the skin at the injection site similarly.  Frequent steroid injection can also weaken and possibly rupture the Plantar Fascial ligament.  Don't let this scare you off form getting an injection.  For patients with significant pain its often the best and quickest ways to break the inflammatory cycle and reduce or stop the pain.   

Radiofrequency Ablation
     If my patients' pain doesn't resolve after trying these treatments then I'll switch my treatment plan and focus on blocking the pain they are experiencing since stopping the cause of the pain has not worked.  This is done by stunning the nerves that transmit the pain from the ligament and blocks the pain.  Stopping the nerve from transmitting pain signals is accomplished through a procedure which uses radiofrequency (a form of electricity) to ablate or stun the nerve.  This procedure, Radiofrequency Ablation, is successful  in stopping pain in approximately 70-80% of patients who's pain is not resolved with the above traditional treatments. We'll save a complete discussion of Radiofrequency treatment of Heel Pain and Neuromas for another blog entry. Visit Neurotherm.com by clicking on the following link, for detailed information about radiofrequency treatment of heel pain including my articles and research.  http://www.neurotherm.com/podiatry_education.htm

 The following products are helpful in treatment and prevention of heel pain

SNEAKERS:  If you want to support your ligament and cushion your heel properly invest in a good pair of athletic sneakers.  A cross trainer or walking sneaker is best. Stick with the major athletic brands like New Balance or Nike.  Don't waste money on Easy Spirit, or Curves or designer sneakers.  If you sneakers are over 6 months old get new ones.  Even if they look good the materials begin to loose their  shock absorption properties.  If you have a wide foot stick with New Balance sneakers and get the appropriate width to match the size of your foot. These sneakers have removable insoles.  This allows the insole to be removed and replaced with an  better more supportive Arch Support or Custom Orthotic.

CUSTOM ORTHOTICS aka Custom Arch Support:   Considered the gold standard in treating fasciiitis.   Orhtotics prevent the arch from flattening, reduce the stretch of the ligament, and cushion the heel.  Podiatrist are trained in understanding the relationship between the mechanics of walking and running and how to design a custom arch support (orthotic) to correct any problems with the way the foot is functioning.  Custom Orthotics are made from a cast or impression of the foot.  The Podiatrist will then have the orthotic fabricated based on a mold of the foot and an exam of the foot function.  Orthotics are helpful in addressing many foot and lower extremity problems.  Some insurance plans cover the cost of orhtotics recognizing that the are successful in treating various conditions.  So again check with you Podiatrist. 


ARCH SUPPORTS(non-custom orthotics):  Arch supports or Orthtotics prevent the arch from flattening, reduce the stretch of the ligament, and cushion the heel.  The problem is that the number of choices in non-custom, over the counter orthotics, is daunting.  The vast majority of the arch supports available at your pharmacy are worthless.   The problem is that most arch supports are made in a generic manner with soft materials which are inadequate in the amount of support they provide.   These devices are not optimal for treating Plantar Fasciitis.  Fortunately there are a few very well made Arch supports that provide proper support at a reasonable price.  These supports use better materials and are constructed to provide better support.  

    The arch supports listed below are some of the best non-custom devices you can get.  They can be hard to find since most pharmacies don't carry these brands.  If you can't find them visit my web store by clicking on the link below the picture.

     SUPERFEET GREEN:
 To see item at our online store click link below:

http://www.ourdoctorstore.com/catanese/store/item.asp?ITEM_ID=331&DEPARTMENT_ID=57

 POWERSTEP:
To see item at our online store click link below:


http://www.ourdoctorstore.com/catanese/store/item.asp?ITEM_ID=741&DEPARTMENT_ID=57

 Night Splints:  There have been numerous scientific studies showing the effectiveness of Night Splints in treating Plantar Fasciitis.  I believe that the effectiveness can be increased if the splint is worn in the evenings while watching TV or reading.  Many people spend 3-4 hours or more off their feet each evening before going to bed.  This in addition to the time you're asleep can amount to 12 hours a day that the ligament and tendons are not optimally stretched and in a relaxed position.  Wearing the Night Splint keeps the ligament and tendons stretched during this time. Some insurance companies cover night splints for fasciitis so check with your Podiatrist.

    NIGHT SPLINT:

 To see item at our online store click link below:

http://www.ourdoctorstore.com/catanese/store/item.asp?ITEM_ID=412&DEPARTMENT_ID=57

PROSTRETCH  PS-100:  Pro-Stretch stretches the foot in the proper position to relieve plantar fasciitis, heel spurs and heel pain, calf muscle pain, and Achilles tendinitis.  This is a very effective and easy to use stretching device.

Just three repetitions of 30 seconds each safely and effectively stretches to relieve lower body pain, easy to work into even the busiest schedule.  You may use this type of device if your are sent for physical therapy.  Many therapist have these in their office.

To see item at our online store click link below:

http://www.ourdoctorstore.com/catanese/store/item.asp?ITEM_ID=199&DEPARTMENT_ID=57

FOOT ROLLER: Designed specifically to massage and stretch the Plantar Fascial ligament.  This device provides superior massaging properties compared to a water bottle and is firm enough to stretch the ligament. 

FOOT ROLLER:
To see item at our online store click link below:http://www.ourdoctorstore.com/catanese/store/item.asp?ITEM_ID=776&DEPARTMENT_ID=57

 

 

Something I always tell my patients is that when there are multiple treatments for any condition it means that there is no one good treatment.  We see this with Fasciitis.  Despite the fact that we are very successful at treating this there is no one treatment that works for everyone. So use all of the measures discussed and you should see results.