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 from ulcers.
  
  
• 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 tendon).
  
  
• 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 indicated.
  
  
• 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 symptoms.
  
  
• 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 indicated.

• 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 without inflammation.

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 below:

• 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 recovery.

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
215-725-1092
Email: dldjwander@aol.com

© 2002 Dr. David S. Wander