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March 2009: Current Concepts in Treating Heel Pain

01 Mar 2009

Dr. Mark Jones is a board-certified podiatrist at Weiss Memorial Hospital. His specialties include foot surgery and sports injuries. Dr. Jones is a consulting podiatrist to Broadway in Chicago. For more information, visit www.thefootdocs.com.

Dr. Mark Jones
Podiatrist
Weiss Memorial Hospital
(773) 685-8400

Current Concepts in Treating Heel Pain

The most common cause for heel pain is plantar fasciitis, a condition known for causing pain in the heel, especially with first steps. Generally this pain subsides after several minutes to a half hour or so.

Some individuals will present with pain in their heels when they run, walk or hike. Others have pain with prolonged standing or at the end of their work day. Often people present having heard the term “heel spur” and relate sharp, throbbing and aching pain in the heel.

What is plantar fasciitis?
The plantar fascia is the name for a long ligament on the bottom of the foot. This ligament develops micro tears, and over time a spur can develop. However, the spur is rarely the cause of the pain. A spur is often a “sign” and not a “symptom.” Repetitive tearing and healing cycles can cause the ligament to thicken, worsening the condition and pain, developing plantar fasciitis.

Why does plantar fasciitis develop?
Most plantar fasciitis is the result of excessive motion of the foot, usually excessive pronation. The foot mechanics place excessive stress on the fascia and tears develop. A change in activity or prolonged standing, weight gain, poor shoe gear such as flip flops, changing walking/running surfaces, and injury (even chronic overuse injury) are a few of the most common causes.

Once the fascia weakens it is more susceptible to tearing, inflammation, scar formation, abnormal collagen alignment and degeneration—a repetitive cycle is put into motion. In the end, the patient may develop a more serious condition called plantar fasciosis.

How is plantar fasciitis diagnosed?
There are several ways to diagnose plantar fasciitis, depending upon the stage of the condition and each individual case.

An exam. For pain with palpation along the bottom of the heel, inside of the heel and sometimes along the arch, the podiatrist collects a detailed medical history and provides a foot and biomechanical examination.

X-ray evaluation. For stress bone response, periostitis, spurring and bone tumors, an X-ray is an excellent way to assess biomechanical bone position.

Diagnostic ultrasound. Diagnostic ultrasound is used to observe fluid/swelling, ligamentous integrity and thickness.

MRI (magnetic resonance imaging). An MRI may be required in more advanced cases.

How can you battle plantar fasciitis?

  • Decrease your activity, especially those activities that worsen the condition
  • For athletes, cross training is an excellent way to maintain strength and endurance while using alternative muscle groups
  • Ice massage the arch and heel
  • Stretching: both passive with a night splint and active stretching
  • Anti-inflammatory medication
  • Arch supports and/or custom-made orthotics
  • Proper shoe gear
  • Weight control
  • Physical therapy
How can your doctor treat fasciitis?
  • Steroid injections (the anti-inflammatory kind). It is important to know that there is a limit to the amount that can be used, since too much steroid can do more harm than good.
  • Custom-made orthotics. Biomechanical control is the key.
  • Taping techniques. These tried-and-true techniques have been working for years.
  • Night splints and/or walking cast boots.
The general population responds well to conservative protocols in four to six weeks, but may take up to three months to relieve symptoms.

What if conservative options fail?
Newer developments in non-surgical and surgical treatments are routinely being scrutinized and researched.

I believe in a conservative approach, but if failure to relieve complaints goes beyond three months, I always discuss surgical options, even just for educational purposes.

EPF (endoscopic plantar fasciotomy). EPF is a minimally invasive surgical treatment for chronic plantar fasciitis. This procedure involves making a small incision on the inside and outside of the heel. A small camera is inserted, followed by microsurgical blades, and the ligament is released. Outcomes are generally well tolerated and with much less risk than open heel surgery.

Open-heel surgery. This is a last-resort surgery and is often used in conjunction with release of a nerve or nerves that innervate the painful fascial area. The bone spur and any bursa (if present) can be removed. Recovery is much longer (three months or more).

Radiofrequency coblation (Topaz). This is a plasma-mediated bipolar radiofrequency technology that uses low temperature to stimulate blood flow (angiogenesis), organize collagen repair and increase in growth factors. This technique can be applied via an open or percutaneous (through the skin with no incisions) approach.

Re-thinking our terminology
The “itis” of plantar fasciitis means inflammation. Many studies have shown that after the first few weeks following injury inflammation decreases. After a few months the blood flow that was increasing has disappeared and the fascial band starts to thicken and lose blood supply. Chronic and repetitive micro-tearing goes on, collagen disorganization develops and the ligament degenerates. The exact point of this transition is up for debate, but nonetheless must be considered. Much of our efforts have involved treatment of the “itis” and our current evolution of thinking is revolving around the more appropriate term plantar fasciosis.

In summary
The key to current treatment concepts is knowledge of the conditions surrounding the development of heel pain. Early treatment is paramount. From patient exam we can determine likely causes and institute an active conservative protocol. Use of diagnostic imaging enables us to differentiate the level of injury and possibility of alternative causes for this pain. And, more advanced surgical approaches enable us to treat those patients who have progressed to a point that conservative options have failed.

For more information
If you would like more information about plantar fasciitis or would like to schedule an appointment, call Dr. Jones’ office at (773) 685-8400.