The most common cause of a painful heel, plantar fasciitis is characterized by pain in the heel when walking after rest (poststatic dyskinesia) then decreasing slowly exercise. The plantar fascia is a ligament extending from the calcaneus to the metatarsal heads of the foot. Plantar fasciitis is the inflammation of the plantar fascia ligament as it attaches to the heel bone or calcaneus.
This inflammation worsens with moments of relaxation as the ligament is allowed to shorten. When the foot is loaded by standing the ligament is stretched and where the ligament is attached to the calcaneus becomes very painful. This pain can follow the plantar fascia up the plantar fascia band into the arch , but is usually isolated to the heel. The plantar fascia becomes inflamed from repeated twisting or torquing of the ligament due to an unstable foot and plantar fascitis develops.
Treatment of Plantar Fascitis
There are several different treatment options available that do not require surgery, however, the longer and more severe a case becomes the more likely it will require surgery. The easiest and most effective way to treat the less severe cases is through the use of:
- Stretching exercises- calf stretching, night splints, and stretching of the foot prior to getting out of bed.
- Icing– take an empty water bottle fill it up and freeze it, roll it across the heel
- Anti-inflammatory medications– Ibuprofen (Advil, Motrin), naproxen (Aleve), or Tylenol, If you are have any history of ulcers in the stomach, bleeding problems, or take blood thinners consult your doctor. These medications are treating the symptoms (inflammation) not the actual cause.
- Orthotics–insoles that are custom fit to your foot by a podiatrist through molding the foot or molded directly to your foot are a staple in the treatment of plantar fasciitis. So called custom orthotics from the Good Feet store or Dr. Scholl’s are not custom fit to your feet. They are generic insoles, these insoles can be helpful, but they are NOT custom fit, thus not offering your feet the balancing they need.
- Weight loss- If you are over weight it is important to get to and maintain a healthy weight for your body. Our feet are responsible for carrying our weight and the stress from carrying extra weight can overwhelm them.
- Injections- Steroid injections in to the points of focal heel pain are very effective. These medications are treating the symptoms (inflammation) not the actual cause.
- Shockwave therapy- This procedure uses deep ultrasound to break up the inflammation and is done in the Doctors office.
Surgical treatment preferences depend on the doctor performing the surgery. Some doctors believe any heel spur must be removed and the plantar fascia must be severed. Other doctors believe just the plantar fascia must be severed. The reason this is important is because the healing times, post operative pain and post operative care are much different. I personally have family members who have just had the plantar fascia resected and feel that it worked perfectly with no complications. Endoscopic plantar fasciotomy is an easy less invasive way of severing the plantar fascia. The recovery is 2 –3 weeks and pain is minimal compared to the other more invasive procedures.
Nerve Entrapments and Heel Pain
There are various nerves in the foot that can malfunction when they experience abnormal pressure. There are a few different nerves in the heel area that can cause heel pain. This pain is different than the pain experienced by plantar fasciitis and is most commonly characterized by burning, tingling, or the feeling of pins and needles being stuck into their feet.
Injections of steroids can be effective at limiting the inflammation around the nerve and breaking down the ligaments, scar tissue, or other structure impinging on the nerve. Orthotics can sometimes relieve the stress on the nerve by changing the biomechanics of the foot.
Surgical resection of the impinging tissue may be required. These procedures depend on the nerve, location, and impinging structure.
Stone bruise of the Heel and Calluses
Occasionally, a bruise or callus can develop under the heel bone or calcaneus. I am grouping these two together because calluses directly under the calcaneus will sometimes cause bruises. Bruises or contusions are nothing more than inflammation of the soft tissues and the pain is often characterized as dull and achy. This pain does not go away or decrease with exercise as it does with plantar fasciitis. Inflammation under a normal weight bearing surface causes pain. This contusions can be caused by many different problems associated with an individuals foot. The more common causes are lack of fat pad under the heel, traumatic injury, over doing it, and poor shoe gear.
Bruised Heal Treatment
Treatment corresponds to the causative factor. Treatments that work well include gel heel pads or insoles, debriding a callus (if one exist), icing, rest, and better shoe gear.
Traumatic Heel Injury
Traumatic injury to the heel other than that causing a bruise or contusion of the soft tissue around the heel would be a fracture of the calcaneus or dislocation of the surrounding joints. Calcaneal fractures and dislocations of joints in the foot are medical emergencies and require an ER visit. These injuries may require surgery or in some cases can be reduced put back in place without surgery. In either case, it will depend on the experience of the physician on call.
Heel Ulcers and Wounds
Ulcers and wounds of the heel are visible but may have more going on that one would expect. These are most commonly seen in patients with peripheral arterial disease (PAD) (PVD), Peripheral Neuropathy (PN), and/or people limited to bed. Wounds of the heel depending on the location can take months or even years to heel if they heel at all. It is important treat the cause of the ulcer and make sure the ulcer is clean. As I tell my patients there are certain factors required to heel this wounds these factors include:
- Adequate blood supply
- Good nutrition
- No infection
- Reduction in or no pressure to the area
If these factors are able to be accomplished a wound can and usually will heal no matter what topical is used.
Heel Pain and Arthritis
Arthritis or degeneration of the joints in the rear foot can cause various pains in and around the joints involved. Degeneration of joints is a normal breakdown of cartilage responsible for cushioning and maintaining lubrication of our moving “bony hinges.” There are many factors which can expedite this degeneration including, genetics, obesity, unstable feet, fractures involving the joints, misaligned joints among other things. Pains are usually described as dull, achy, stiffness, and sometimes have post-static dyskinesia (pain after rest.)
Conservative treatments include orthotics, steroid injections, NSAID’s, and supplements to aid in lubrication. Orthotics are used to help stabilize the foot and reduce motion of the joints involved. With the increased stability and reduction in joint motion there is often a significant reduction in the pain. It is important to understand none of the conservative or surgical treatments are able to undo the damage that has been done. In all cases we are treating the symptoms. Steroids are potent anti-inflammatories and can reduce acute inflammation associated with flare ups. NSAIDS or Non-Steroidal Anti-Inflammatories can be used to reduce pain as needed. As stated earlier consult your doctor if you have a history of any bleeding problems including but not limited to gastric ulcers, people on Coumadin, or hemophiliacs. Supplements like glucosamine and chondroitin have been shown to reduce further damage of the joints.
The surgical treatments for arthritis in the area of the heels often result in fusions of the joints involved. This can require multiple fusions if there are more than one joint involved. A fusion is a permanent locking of the joint by removing the joint and placing screws or other souses of fixation to stabilize the bones and allow the bones to heel. If there is no motion there is no pain due to arthritis. Fusions stopping the motion in one or more joints causes an increase in the need for motion in other joints. As one can imagine this can cause other problems and chronic pain. The success rate for these procedures varies greatly from patient to patient and often depends on how much pain the patient had prior to surgery.