Understanding Heel Pain

By Brian K. Bailey, D.P.M., M.S., Body-Mind-Spirit Podiatric Care

Understanding Heel PainDo your first few steps out of bed in the morning cause severe pain in your heel? Or does your heel hurt after jogging or playing tennis?

Most commonly, heel pain is caused by inflammation of the plantar fascia — the tissue along the bottom of your foot that connects your heel bone to your toes. The condition is called plantar fasciitis (PLAN-tur fas-e-I-tis).

Plantar fasciitis causes stabbing or burning pain that’s usually worse in the morning because the fascia tightens (contracts) overnight. Once your foot limbers up, the pain normally decreases, but it may return after long periods of standing or after getting up from a seated position.

In most cases, you can kick the pain of plantar fasciitis without surgery or other invasive treatments. And you can take steps to prevent plantar fasciitis from recurring.

While plantar fasciitis is the most common cause of heel pain, there are several other causes. As I discussed in my lecture at the Kentucky Podiatric Medical Association annual meeting in April, other causes can include calcaneal apophysitis (children) 9 -14; posterior tibial tendon dysfunction; arthritis; gout; stress fracture; Achilles tendon problems; bone cyst; sub-calcaneal bursitis; pinched nerve/nerve entrapment; neuropathy; and low back or disk problems.

Signs and symptoms
Plantar fasciitis usually develops gradually, but it can come on suddenly and be severe. Plantar fasciitis can affect both feet, but it usually occurs in only one foot at a time. Watch for:
• Sharp pain in the inside part of the bottom of your heel, which may feel like a knife sticking in the bottom of your foot
• Heel pain that tends to be worse with the first few steps after awakening, when climbing stairs or when standing on tiptoe
• Heel pain after long periods of standing or after getting up from a seated position
• Heel pain after, but not usually during, exercise
• Mild swelling in your heel

Causes
Under normal circumstances, your plantar fascia acts like a shock-absorbing bowstring, supporting the arch in your foot. But, if tension on that bowstring becomes too great, it can become irritated or inflamed. The causes of plantar fasciitis can be:
• Posterior leg muscle tightness. This is the most common cause and is best treated with an Equinus Brace.
• Physical activity overload. Plantar fasciitis is com-
mon in long-distance runners. Jogging, walking or stair climbing also can place too much stress on your heel bone and the soft tissue attached to it, especially as part of an aggressive new training regimen. Even household exertion, such as moving furniture or large appliances, can trigger the pain.
• Arthritis. Some types of arthritis can cause inflammation in the tendons in the bottom of your foot, which may lead to plantar fasciitis.
• Diabetes. Although doctors don’t know why, plantar fasciitis occurs more often in people with diabetes.
• Faulty foot mechanics. Being flat-footed, having a high arch or even having an abnormal pattern of walking can adversely affect the way weight is distributed when you’re on your feet, putting added stress on the plantar fascia.
• Improper shoes. Shoes that are thin-soled, loose, or lack arch support or the ability to absorb shock don’t protect your feet. If you regularly wear shoes with high heels, your Achilles tendon — which is attached to your heel — can contract and shorten, causing strain on the tissue around your heel.

Risk factors
Your risk of developing plantar fasciitis increases if you are:
• Active in sports. Activities that place a lot of stress on your heel bone and attached tissue are most likely to cause plantar fasciitis. This includes running, ballet dancing and aerobics.
• Flat-footed or have high arches. People with flatfeet may have poor shock absorption, which increases the stretch and strain on the plantar fascia. People with highly arched feet have tighter plantar tissue, which also leads to poor shock absorption.
• Middle-aged or older. Heel pain tends to be more common with aging as the arch of your foot begins to sag, putting stress on the plantar fascia.
• Overweight. Carrying around extra pounds can break down the fatty tissue under the heel bone and cause heel pain.
• Pregnant. The weight gain and swelling that accompany pregnancy can cause ligaments in your body — including your feet — to relax. This can lead to mechanical problems and inflammatory conditions.
• Working on your feet. People with occupations that require a lot of walking or standing on hard surfaces, including factory workers, teachers and waitresses, can damage their plantar fascia.
• Wearing shoes with poor arch support or stiff soles. A closet of poorly designed pumps, loafers and boots can mean plantar problems.

When to seek medical advice
If you have heel pain, try self-care measures, such as stretching and changing your activities. If you don’t see much progress after a few weeks of home treatment, see your foot doctor (podiatrist).

Seek help sooner if your pain worsens, despite home treatment. If you have diabetes or another condition that causes poor circulation, see your doctor for an early evaluation of any changes in your feet.

Screening and diagnosis
Your doctor will ask you about your symptoms and look for points of tenderness in your foot. This can help rule out other causes of heel pain, such as stress fracture, tendinitis, arthritis, nerve irritation or a cyst. Your doctor must take digital X-ray to make sure you don’t have a stress fracture.

Diagnostic ultrasound exams are done on all our heel pain patients. If ultrasound shows a thickening of more than 4.0 mm this is diagnostic of plantar fasciitis it will also show if there are tears in the plantar fascia. X-rays will not show this.

Sometimes, an X-ray shows a spur of the bone projecting forward from the heel bone. In the past, bone spurs were often blamed for heel pain and removed surgically, but doctors have found that they’re typically not the cause of pain. Surgery to remove spurs is rare.

Complications
Ignoring plantar fasciitis may result in a chronic condition that hinders your regular activities. You may also develop foot, knee, hip or back problems because of the way plantar fasciitis changes your walking motion.

Treatment
If self-care techniques don’t help, your doctor might suggest other treatments to heal your heel.

Conservative treatment
Nonsurgical treatments that may promote healing include:
• Stability running shoes. We measure for and dispense Saucony stability shoe sometimes covered by insurance.
• Sport taping. Low Dye straping.
• Night splints. Your doctor may recommend wearing a splint fitted to your calf and foot while you sleep. This holds the plantar fascia and Achilles tendon in a lengthened position overnight so that they can be stretched more effectively. To be effective we use an EQ brace that extends behind the knee to stretch the gastrocnemius muscle and the hamstrings.
• Orthotics. Your doctor may prescribe OTC orthotics or custom-fitted shoe inserts (orthotics), which are specially molded to your feet, to help distribute pressure to your feet more evenly.

Surgical or other procedures
If conservative treatment doesn’t provide relief, you might consider:
Corticosteroids. When other treatments don’t work, your doctor may suggest one or two injections of corticosteroid medication into your foot for temporary relief. Multiple injections aren’t recommended because they can weaken your plantar fascia and possibly cause it to rupture, as well as shrink the fat pad covering your heel bone.

Extracorporeal shock wave therapy. In this procedure, sound waves are directed at the area of heel pain to stimulate healing. It’s usually used for chronic plantar fasciitis that hasn’t responded to more conservative treatments. Early studies on this procedure reported positive results, but some recent studies have had limited success in treating plantar fasciitis. More research may determine if extracorporeal shock wave therapy is an effective treatment for heel pain, and if so, what kind of machine and treatment regimen seems to work best.

Complications of this procedure may include bruising of your skin, swelling, pain, numbness or tingling, and rupture of the plantar fascia. This therapy isn’t used for children, pregnant women or patients with a history of bleeding problems.

Surgery. Only a very small percentage of people need surgery to detach the plantar fascia from the heel bone (plantar fasciotomy). It’s generally an option only when the pain is severe and all else fails. Side effects include a weakening of the arch in your foot.

Prevention
You can take some simple steps now to prevent painful steps later.

Maintain a healthy weight. This minimizes the stress on your plantar fascia. I have a special diet that patient lose 4 pounds a week if they are obese and 2 pounds a week if they are overweight.

Choose supportive shoes. Give stilettos the boot. Also avoid shoes with excessively low heels. Buy shoes with a low to moderate heel, good arch support and shock absorbency. Don’t go barefoot, especially on hard surfaces. I recommend a stability running shoe. We measure our patients and dispense these in the office. Some insurances cover these.

Don’t wear worn-out athletic shoes. Replace your old athletic shoes before they stop supporting and cushioning your feet. If you’re a runner, buy new shoes after about 400 miles.

Start sports activities slowly. Warm up before starting any athletic activity or sport and start a new exercise program slowly.

Wake up with a stretch. Before you get out of bed in the morning, stretch your calf muscles, arch and Achilles tendon by reaching for your toes and gently flexing your foot. This helps reverse the tightening of the plantar fascia that occurs overnight.

Self-care
By following these self-care tips, you may be able to eliminate heel pain without further treatment.

Apply ice. Hold a cloth-covered ice pack over the area of pain for 15 to 20 minutes three or four times a day or after activity. Or try ice massage. Freeze a water-filled Styrofoam cup and roll it over the site of discomfort for about five to seven minutes. Regular ice massage can help reduce pain and inflammation.

Decrease your miles. You probably won’t have to permanently retire your running or walking shoes, but it’s a good idea to cover shorter distances until pain subsides.

Take up a no- or low-impact exercise. Swap swimming or bicycling for walking or jogging. You’ll likely be able to return to your regular activities as heel pain gradually improves or disappears. However, some people find that the only way to avoid a recurring problem is to permanently modify their aerobic activities.

Brian K. Bailey, D.P.M., M.S., is a podiatrist with Body-Mind-Spirit Podiatric Center in Ashland, Ky. The office is located at 500 14th Street, at the intersection with Central Avenue. New patients are welcome. For more information, please call the office at (606) 324-FOOT (3668).

Dr. Brian K. Bailey is a Podiatric Physician & Surgeon with a private practice located in Ashland, KY. He is also a Clinical Professor of Podiatric Medicine & Surgery at Pikeville College of Osteopathic Medicine and a Personal Wellness Coach & Fitness Trainer. Dr. Bailey has written several books, including: Secrets to Happiness, Inner Peace and Health, Metabolic Syndrome 2011, Nutrients for Prostate Cancer Prevention and Eradication, Breast Cancer Prevention and Wholistic Treatment, and Prostate Cancer Prevention and Wholistic Treatment.

Body-Mind-Spirit Podiatric Center in Ashland
500 14th Street, Ashland, Kentucky, 41101
Phone (606) 324-FOOT

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