Features December 2004 Issue

Heal Your Heel Pain

The causes of heel pain are not always apparent, but there are old and new ways to treat it successfully.

Although there are several theories on how it develops, “plantar fasciitis is still a mystery,” says Brian Donley, M.D., an orthopaedic surgeon at The Cleveland Clinic. “The ailment can seemingly materialize from nowhere.”

Plantar fasciitis is an injury in which the fibrous tissue (plantar fascia) that runs along the bottom of the foot between the heel and toes becomes inflamed due to over-use. The longer the inflammation lasts, the more likely the lining of the heel will also be torn away. The shelf-like structure that develops in response to the injury is as wide as the heel bone and is called a heel spur. There is a technical difference between the two conditions, but the terms plantar fasciitis and heel spur are often used to describe the same thing.

Toe walkers, people with anatomical abnormalities, and those with tight calf muscles are all in the high-risk group. Women are more likely to develop it than men, and you are vulnerable if you’re overweight, have flat feet, or work in a job that requires walking or standing on a hard surface.

Symptoms
The primary symptom is gradually worsening heel pain. There could also be a feeling of a dull, dime-sized stone buried in the heart of the heel. Typically, it hurts more in the morning, less during the day, and the pain intensifies when you put weight on the foot. It is not uncommon for the foot to hurt more after exercise than during it.

Causes
Possible causes are excessive foot pronation (ankle rolling inward), shoes with worn-out heels, shoes that do not properly support the foot, walking or jogging on hard or uphill surfaces, or dramatic increases in an exercise program. It can also be caused by heel trauma that is associated with stepping on a hard object.

Treatment
The healing process can be agonizingly slow because the condition is aggravated with every step. Treatment includes rest, ice, anti-inflammatory pain medication, wearing cushioned pads under the heel, orthotics (heel inserts), and stretching. For the first few days, stretching can cause the pain to worsen, but eventually flexibility exercises will reduce the pain.

Dr. Donley recommends wrapping the foot and ankle with an elastic bandage over a night splint set at a 90-degree angle before going to sleep at night. He also suggests immobilizing the foot at night with pillows. If the pain does not go away after six weeks, see a physician. More aggressive treatment options are cortisone injections, walking casts, surgery, and extracorporeal shock wave therapy (ESWT).

ESWT (see March 2004 Arthritis Advisor) is the latest treatment for plantar fasciitis. High-energy shock waves are transmitted into an affected area to stimulate the healing process. Patient satisfaction during initial clinical trials ranged from 60 to 85 percent, but subsequent studies have shown less than compelling results.

“Some people benefit from it, and some studies support it,” says Dr. Donley, “but other studies have shown it not to be effective. Given that information, shock wave therapy seems to be a reasonable choice if more conservative measures (stretching, icing, night splints) are not effective. There are no significant risks, but cost is a factor in cases where insurance companies do not cover the procedure.”

If plantar fasciitis is not treated, it can become a chronic condition. It can also lead to knee, hip, and back problems because your body will force you to walk differently in order to compensate for the pain.

Prevention
There is no conclusive evidence that stretching will prevent plantar fasciitis, but a systematic stretching program is generally a good idea for the foot and the ankle. Activities such as riding a stationary bicycle, water exercise, and swimming are recommended because they do not put pressure on the heel.

The good news is that nearly 90 percent of the people with plantar fasciitis who seek treatment show improvement within two months.