Special Report on Heel Pain Plantar Fasciitis (Heel Pain) Plantar fasciitis is caused by inflammation of the connective tissue that stretches from the base of the toes, across the arch of the foot, to the point at which it inserts into the heel bone. Also called "heel spur syndrome," the condition can usually be successfully treated with conservative measures such as use of anti-inflammatory medications and ice packs, stretching exercises, orthotic devices, and physical therapy. What is the problem? A pain has developed at the bottom of the heel, and it has gotten worse. The patient was not aware of having had any injury that caused it. What does it feel like? It feels like a dull ache most of the time, but when the patient first gets out of the bed in the morning, or when getting up after sitting for a period of time during the day, the pain in the heel is sharp and stabbing. It almost feels like the heel has been bruised, from stepping on a rock barefoot. Testing for Plantar Fasciitis Since there are several causes for heel pain, we need to pin-point the exact location of the pain is in order to diagnose the basic underlying cause for the problem. Testing is simple and generally pain-free. It's important to find out WHERE it hurts, not just HOW MUCH it hurts. After excluding general medical conditions that might cause the condition, the exam is localized to the heel and surrounding structures. The important anatomical structures are the heel bone (calcaneus) and the tissues that attach to the bottom of the heel (plantar fascia). We use X-rays, which allow us to visualize the bones of the foot and make sure there is no fracture of the heel bone. We also use ultrasound, which will allow us to visualize the plantar fascia to determine its thickness and to see if there is any surrounding fluid accumulation or tear. What causes Plantar Fasciitis? There is a tight ligament (band of fibrous tissue) that stretches across the arch, from the ball of the foot to the heel bone, called the Plantar Fascia. When we walk, our feet have a tendency to roll inward, toward each other, in a motion that we call pronation. When feet pronate, they flatten, stretch out and the arch elongates. This causes excessive pulling on the Plantar Fascia ligament and attachment of the ligament to the heel bone begins to separate. An injury occurs where the ligament progressively tears off of the heel, fiber by fiber. Bleeding occurs next to the bone and inflammatory fluids accumulate between the ligament and the bone, forming a Bursitis, or fluid-filled sack. Over time, the body lays down scar tissue, in an attempt to "glue" the detached ligament fibers back on to the bottom of the heel bone. Over the course of 3-5 years, the scar tissue calcifies, and this calcium deposit eventually becomes visible on x-ray as the heel spur. This inflammation of this plantar fascia ligament is called Plantar Fasciitis, and in addition to the bursitis, is what causes the pain. The bone spur itself has no nerve endings and doesn't hurt. It is just an associated finding that tells us that the inflammatory process, the bursitis and plantar fasciitis have been present for a long time. There are several reasons that this chronic injury can occur. Recent weight gain and increased activity level often start an episode. A person who has been mostly sedentary, who suddenly takes up an exercise program of walking or running is a prime candidate. A change of shoes from well supporting walking or athletic shoes to floppy sandals can do it. When the arch of the foot collapses or flattens, the plantar fascia is stretched, causing the injury where it attaches to the heel bone. Finally, conditions which cause generalized increased inflammation, like osteoarthritis or rheumatoid arthritis can cause this. There is one more, smaller category of patients, who have heel pain due solely due to a loss of the protective fat pad cushion on the bottom of the heel. We rely on the heel fat pad, that marvelous structure, to cushion our heel, like the sole of a good running shoe does, from the impact that a modern human body makes when it lands on it. All tissues atrophy or thin as we get older, giving many seniors their "drawn" appearance. The thinned heel fat pad permits bruising, as our body weight is born by a much smaller, bony-hard and more concentrated area. Treatment It is better to rest the heel using common sense. When you are off your feet, the injury is healing and getting better. When you are standing, without any foot support, the heel is getting injured further. When you are standing when wearing orthotics (foot supports) and well supportive shoes, the injury decreases dramatically, but usually is not eliminated altogether. So, during the treatment period, if you have the choice of sitting or standing…sit! If there are no health reasons to avoid them, a few weeks use of an over-the-counter anti-inflammatory medication may eliminate the pain. How does a podiatrist treat Plantar Fasciitis? Treatment for this condition is multifaceted. There are 3 main goals that must be accomplished. First, we decrease the inflammation with anti-inflammatory medications, cortisone shots and ice. Secondly, we begin a course of stretching for the calf muscles. Thirdly, we support the fascia with taping, orthotics and an air heel brace. These measures will eliminate the problem in about 85% of patients within 6-8 weeks. Some get better very quickly while others take the full 8 weeks. How can I prevent it from coming back? Recurrence is possible after treatment but if the patient continues to employ good mechanical foot control by wearing orthotics, stretching and wearing good supportive walking or athletic shoes, chance of recurrence is minimized. If you or someone you love has been experiencing heel pain, the time is NOW to get it evaluated. Delay of care can lead to significant pain and immobility. Don’t let fear keep you away from the treatment you deserve. Committed to you health, Dr. Craig Conti Sarasota Foot Care Center www.sarasotafootcarecenter.com
