Heel pain is one of the most common foot complaints podiatrists treat. In a recent American Podiatric Medical Association (APMA) study it was found that nearly 40% of all Americans suffer from heel pain at some point in their lives. While there are many causes of heel pain, plantar fasciitis is by far the most prevalent. Commonly known as heel spur syndrome, plantar fasciitis is an overuse syndrome. The plantar fascia supports the arch of the foot, when it is over worked it becomes inflamed. If the inflammation is allowed to continue it will lead to bursitis and eventually a spur at the bottom of the heel bone. Plantar fasciitis is characterized by pain upon first rising in the morning. In the early stages the first few steps after being off your feet are the worst, the pain gradually subsides after a few steps. As the condition progresses the pain may worsen the longer you are on your feet. Often the affected heel will throb after getting off your feet at the end of the day.
Plantar fasciitis can be caused by a combination of factors, knowing what is causing your pain is the first step toward finding a cure. Some of the typical causes include: impact type exercise, weight gain, concrete or hard tile flooring and collapsing of the arch. Choice of shoes or the lack of shoes however is by far the most common cause. In a recent APMA survey 45% of Americans attributed their heel pain to wearing uncomfortable or ill-fitting shoes. Flat, thin, dress, deck or boat type shoes are the typical culprits. The closer the shoe is to going barefoot the worse it is. If you can easily bend the shoe in half from toe to heel this may be the cause of your heel pain. Pronation or a subtle collapsing of the arch can affect even high arched feet and lead to plantar fasciitis.
Supportive athletic, walking, tennis, running or hiking shoes should be the first change to your wardrobe when heel pain appears.
New Balance 547
Available at: Dick’s
Ocala Sports, Dicks, Gander Mtn
Replace any worn out shoes and avoid going barefoot. Instead of going barefoot around the house invest in some slides, mules or clogs with built in arch support; for use around the house.
Merrell jungle slides
Available at Ocala Sports
Add athletic, sport or work type arch supports to your shoes.
ten second ¾ rigid arch support
available at: Bitting’s Pharmacy, Ocala Sports, Dick’s
Throw away the heel pads, cushions and gel innersoles, they don’t work for plantar fasciitis. Daily use or work shoes should be frequently replaced, at least every 6 months, running shoes should be replaced at approximately 500 miles. Even infrequently used yard work shoes should be evaluated for signs of aging, the materials which provide shock absorption will dry out over time. More important than the name brand of a shoe is qualities. A lace up shoe is best, the sole should not bend in the middle, the heel counter should be firm and not collapse when squeezed from the sides. Wear sport specific shoes: running shoes for running, tennis shoes for tennis, walking shoes for walking, etc. not cross trainers.
Weight and exercise often work together to make the perfect storm. You can’t loose weight without exercising but you can’t exercise because your feet hurt. This may require a gym membership in order to take advantage of low or non-impact exercises. Gym quality treadmills or run/walk paths often have better shock absorbing treads for lower impact than road surfaces or home treadmills. EFX or elliptical machines provide similar aerobic exercise without all the impact on your heels. Exercise bikes typically take longer to get the same amount of exercise, but provide for no impact. Swimming is an excellent form of exercise which will not affect your heels. Obviously diet and exercise together are needed for effective weight loss to decrease the impact of daily activity on your feet.
Hard surfaces are often responsible for heel pain. Concrete at work and tile floors at home greatly contribute to the number of cases of plantar fasciitis. Much of the effect of these surfaces can be counter acted with the use of proper shoes and arch supports. However if at all possible cover any hard surfaces where you stand with thick cushion material or mats.
Your daily routine when dealing with heal pain should include exercising or stretching your feet and ankles before even getting out of bed. Work your feet like you were applying the gas pedal in your car. Write the alphabet with your feet. Use thera band or a towel to pull your feet up stretching the calf muscles, hold stretch for 10 seconds and repeat 10 times.
After you get out of bed, lean against the first wall and further stretch the heel cords and calf muscles. Hold stretch for 10 seconds and repeat 10 times.
Repeat stretches prior to any sport or exercise routine.
Additional stretch using a step can be utilized if you have good balance or something to hold onto. Stretch the heel cords and calf muscles. Hold stretch for 10 seconds and repeat 10 times. Repeat stretches prior to any sport or exercise routine.
Anti-inflammatory or arthritis medicines may be helpful for plantar fasciitis if you can take them; check with your physician. Advil and Aleve not Tylenol for this problem. Make sure and eat before taking them and do not take them if you have any stomach problems, ulcers, reflux, hiatal hernia or kidney disease.
At the end of the day you should ice your heels. 10 minutes of ice at night could save you 10 minutes of pain in the morning. Rolling a cold soda can under your heel and arch can relieve inflammation and decrease morning pain.
Massaging the arch and heel can help also. Sitting with your foot on the opposite knee pull all your toes toward your shin with your fingers. Confirm the stretch by feeling for the cord like plantar fascia and massage it with you thumb. Hold the stretch for 10 seconds and repeat 10 times.
If these simple tips haven’t relieved your heel pain it is time to get a proper diagnosis and treatment from a physician. If you do not already have a podiatrist or foot and ankle surgeon that you are established with, the best way to find one is through people you know. Find out if family or friends go to a podiatrist. My preference is not to go to the one with the billboard add, there may be a reason why they need to advertise that heavily. For a list of board certified physicians is your area you can go to footphysician.com.
A typical office visit for heel pain may include an x-ray and examination of the extremity. While the most common cause of heel pain is plantar fasciitis other possibilities include: heel stress fractures, tarsal tunnel syndrome, and gouty arthritis. Treatments may include ultrasound, taping, prescription ant-inflamatories, physical therapy, night splints, custom molded arch supports and cortisone injections. Heel injections into a sore foot can be painful, so in our practice a nerve block is typically given up around the ankle to numb the area prior to the heel injection. In some cases such as uncontrolled diabetes alternative medications may be used instead of a steroid. There should be no pain at all the day of the injection, the day after the heel may be sore from the injection. Plan ahead so that there is a light schedule if you think you might need an injection, use ice and take anti-inflamatories if you can. Each day the pain will subside so that by the end of the week the pain should be almost gone, the effect of the injection will last up to a month. More than one injection may be necessary if there is a lot of inflammation. Typically a maximum of three injections are attempted. If your pain has not resolved after three injections and the diagnosis is plantar fasciitis surgery will need to be considered.
The most common surgery for plantar fasciitis is endoscopic. The small ¼” incisions and equipment used are very similar to that used in arthroscopic surgery. Typically endoscopic surgery is much less invasive and recovery times much shorter that traditional surgery. These procedures are almost exclusively done outpatient with no hospital stay and local anesthetic with sedation utilized. Most patients walk immediately after surgery, but this is surgeon specific. A bandage and surgical shoe are worn for 2 ½ -3 weeks and pain level by most patient accounts is no worse than before surgery. No surgery is 100% effective and endoscopic plantar fasciotomy is no exception. Patients typically report 90% improvement 90% of the time with this procedure. Of course there are always new procedures and for heel pain, that would include a lithotripsy type surgery in which no incisions are needed. Preliminary results show that often more than one surgery may be necessary as there is an approximate50% success rate with the ESWT procedure. Even though this surgery has been available for a while it is not utilized very often as most insurance carriers do not cover the procedure.
Dr. Paul Steinberg is board certified by the American Board of Podiatric Surgery and a Fellow of the American College of Foot and Ankle Surgeons with offices in Ocala and Belleview. For more information go to www.Steinbergpodiatry.com.
Endoscopic Plantar Fasciotomy Procedure