Heel pain is one of the most common ailments treated by foot and
ankle specialists. Many different disorders can cause heel pain,
such as arthritis, collagen diseases, overuse, trauma, stress fractures,
and nerve entrapments. However, the overwhelming majority of heel
pain is caused by plantar fasciitis, also known as heel pain syndrome.
Plantar fasciitis/heel pain syndrome is an inflammation of a thick
band of tissue called the plantar fascia at the bottom of the foot.
The inflammation of the plantar fascia at its origin (at the heel
bone, or calcaneus) causes the classic symptoms of pain at the bottom
and/or side of the heel. It is often most painful upon arising in
the morning or when standing after sitting for a brief period. The
pain results from the stretching of the plantar fascia after it
has tightened during rest.
Heel spurs may not appear on the x-rays of patients with acute
heel pain. Conversely, heel spurs of all sizes are often seen on
x-rays of patients who do not have any heel pain. If a heel spur
does exist, it is usually a shelf of bone rather than a small, sharp
protrusion of bone, as most patients imagine. In other words, the
presence of a heel spur is no indication of the amount of pain that
exists. The pain is not usually from the heel spur, but from the
stretching and inflammation of the plantar fascia. Therefore, initial
treatment is directed at decreasing the pulling and tightness of
the plantar fascia, and supporting the fascia during weight-bearing
to decrease inflammation.
Conservative care can provide relief of symptoms for 90 to 95 percent
of patients suffering from plantar fasciitis/heel pain syndrome.
Most of the common conservative treatments are listed below:
- Anti-inflammatory medication taken by mouth, such as Motrin,
Advil, Naprosyn, DayPro, Relafen, Vioxx, Celebrex, or aspirin.
These medications treat the symptoms of pain and inflammation,
but do not treat the cause of the pain. These medications cannot
be taken by patients who are allergic to aspirin or suffering
- Heel cushions with or without cutout areas in the heel. These
are usually of very little value unless the heel pain was caused
by a bruise. In true plantar fasciitis/heel pain syndrome, the
heel cushions treat only a small portion of the symptoms.
- Heel cups. Heel cups come in many varieties. They are often
used in conjunction with other methods, but are rarely successful
in treating the problem.
- Physical therapy via whirlpool, ultrasound, H-wave ice, and
most importantly, stretching exercises. This treatment is often
quite effective because it treats the symptoms (pain and inflammation)
as well as the cause (tightness of the plantar fascia and Achilles
- Taping/strapping the foot. This method often provides dramatic
temporary relief for patients. This is because the taping addresses
the cause of the problem and supports the plantar fascia. If this
temporary solution helps, a more permanent support is usually
- Orthoses, often known as orthotics. Orthoses are inserts for
your shoes that mechanically correct the foot as well as support
the plantar fascia, therefore reducing the discomfort. Often referred
to as "glasses for your feet," orthoses are available
in many over-the-counter styles or can be custom made for your
foot. They may be soft, flexible, semi-rigid, or rigid. Orthoses
are usually utilized if taping/strapping of the foot reduced the
- Injections of a mixture of local anesthetic and cortisone.
Although relief of pain and inflammation is usually very good
with injections, this treatment does not address the cause of
the problem. It is generally accepted that no more than three
localized injections should be given in a one-year period. Multiple
injections in the same location can weaken the tissue and cause
atrophy of the tissue and fat in the heel area.
- Soft tissue supports such as the Fabrifoam Pronation Spring
Control and Counter Force brace. These support the plantar fascia
and are often a simple and cost-effective way to decrease symptoms.
- Weight loss. Decreasing pressure on the heel by reducing body
weight can often be quite beneficial when it is appropriate and
- Appropriate footwear. The right shoes can play a major role
in relieving discomfort. A high quality running or walking shoe/sneaker
with the proper balance of support and cushioning can often result
in dramatic improvement. Products such as Birkenstock shoes and
sandals can provide significant relief due to the form-fitting
cork footbed. This often has the same benefits as inserts or orthoses.
- Casting. Placing the foot and lower leg in a cast for several
weeks allows the tissues to slowly stretch and the inflammation
to subside. The majority of cases respond to other methods of
treatment, and casting is seldom necessary.
- Night splints. These devices are worn to bed or while at rest.
They place a constant passive stretch on the plantar fascia and
Achilles tendon in order to prevent tightness and to promote stretching
For the 5 to 10 percent of patients who do not obtain relief with
conservative care, more specialized tests such as blood work, MRIs,
bone scans, nerve conduction studies, and other studies can be performed
to rule out other causes of heel pain. If plantar fasciitis is found
to be the cause, newer surgical techniques and Extra Corporeal Shock
Wave Therapy (ESWT) usually allow for a quicker recovery than was
provided by previous treatments. These treatments are described
- Extracorporeal Shock Wave Therapy (ESWT). This newer, completely
non-surgical shock wave treatment allows a patient to walk out
afterward in shoes/sneakers, with no stitches, bandages, or supports.
Patients may return to work immediately, with some restrictions
on activities. Shock wave therapy has been used for several years
in Europe with excellent results. Although availability in the
United States is currently limited, it is constantly increasing.
Recent studies from Massachusetts General Hospital (affiliated
with Harvard Medical School) have reported success in 92 percent
of the patients surveyed at the end of one year. Our office is
one of the first in Philadelphia to offer ESWT and our patients
have been very pleased with the results. We highly recommend this
treatment to patients who have not had success with conservative
care, prior to considering surgery.
- Surgery. It must be emphasized that 90 to 95 percent of patients
that suffer from heel pain do not require surgery, and can find
relief from their symptoms with conservative care or ESWT. However,
surgery is used when conservative measures have not been successful,
or when the patient has decided that surgery is the best choice.
The newer surgical methods, called endoscopic plantar fasciotomy,
involves releasing a portion of the tight plantar fascia with
the use of an endoscope inserted through a half-inch incision.
The scope allows for accurate placement, with monitoring of the
procedure and visualization of the tissues on a television monitor.
This less invasive technique reduces trauma to the tissues, which
often results in decreased post-operative discomfort and a quicker
If you are suffering from heel pain or suspect you might have plantar
fasciitis, visit your podiatrist for an evaluation and recommendation.
Many treatment options are available to help you.
Dr. David S. Wander
Board Certified-American Board of Podiatric Surgery
Fellow, American College of Foot & Ankle Surgeons
6911 Castor Avenue
Philadelphia, Pa 19149
© 2002 Dr. David S. Wander