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For nine months, I could not run because of the severe pain in the Achilles on my left heel. After doing eccentric stretching, I was able to run again. If you are experiencing heel pain from Achilles Tendinosis rather than Plantar fasciitis, please go to: http://www.coachr.org/achilles.htm

Heel pain treatments stretch patients’ tolerance

By: John H. Walter, Jr., DPM

One of the most common foot complaints from patients is of "heel pain." Heel pain treated by podiatrists and other biomechanics practitioners is usually associated with the term "heel spurs," which the general public considers incurable or requiring surgical removal. In the vast majority of cases, this is not true. People with heel pain will live with the pain for months, if not years, before seeking medical advice and will call a doctor only after the pain becomes intolerable or a spouse becomes tired of the complaining.

The presence of a plantar heel spur projecting from the medial tubercle of the calcaneus is usually named as the cause of pain.1 In fact, the spur is not the cause of most heel pain since spurs can exist for years before pain develops. In addition, many people without spurs have severe pain. I have treated hundreds of patients for heel pain with no spurring present, and hundreds of patients with large spurs who have had no heel pain at any time. Therefore, we can deduce that plantar calcaneal spurring is not the cause of most plantar heel pain. Radiographs are usually of little value if taken only to determine the presence of plantar heel spurs.

Heel That Pain

Plantar fasciitis, an inflammation of any portion of the plantar fascia from its origin at the medial and lateral tubercles of the calcaneus (heel bone) extending distally into the toes, is mostly biomechanical in origin. Plantar fasciitis more commonly occurs at the proximal attachment or origin of the plantar fascia. The onset of plantar heel pain is usually gradual and can follow a period of over-activity, walking on hard surfaces, wearing an uncomfortable or unsupportive shoe, or walking barefoot.

Nurses, cooks, laborers, and others who work on tile or concrete surfaces are at risk. Although excessive body weight will contribute to difficulty in treatment, it is not a major factor in the onset or perpetuation of plantar fasciitis. Weight loss is only a small part of the treatment for pain-free ambulation.

Painful Attachment

Plantar heel pain, or plantar fasciitis, is generated by the pull of the plantar fascia at its origin at the medial tubercle of the calcaneus. Although some patients complain of fascial pain in the arch, it seems that the attachment of the plantar fascia at the heel is the proverbial "weakest link of the chain." The pain is secondary to contracture of the inflamed plantar fascia when the foot is relaxed and non weight-bearing. Pain improves with ambulation only to recur toward the end of the day. There is generally little or no pain with rest.

Tall, short, thin, and heavy men and women of all ages and races are affected by heel pain. High-arched feet, low-arched feet, and foot types in between are not immune to developing plantar fasciitis. In my more than 20 years experience, the flexible flat foot is the most difficult to render pain-free because of the degree to which the arch collapses when the patient moves from a non weight-bearing to a full weight-bearing position.

Plantar fasciitis, bursitis, periostitis, and myositis are terms that have been used to describe or diagnose heel pain that occurs at the medial aspect of the plantar heel. Pain that is worse when the person stands up first thing in the morning or after sitting for 10 minutes or more is the hallmark of this problem. This pain after rest is termed "post-static dyskinesia."

Pain with standing after sleeping or sitting as seen in patients with plantar fasciitis is not a symptom associated with stress fractures of the calcaneus, Reiter's syndrome, rheumatoid or psoriatic arthritis, or neuritis.2 Subtalar joint arthritis of the posterior articulating facet of the calcaneus and talus can be either traumatic in origin or from the degenerative "wear and tear" type of arthritis, but neither has post-static dyskinesia as a classic symptom.

Walking causes the pain to subside, but it does not usually disappear completely. As the day progresses, symptoms that were first experienced after getting out of bed return.3 This condition is generated simply because the patient's foot is relaxed during the night. There is no strain on the foot when it is nonweight-bearing.

A normal response is to walk on the toes or the sides of the feet to minimize the pain. This attempt to avoid the pain actually aggravates it, however, and can lead to other problems related to altered gait patterns. Classic signs of heel pain (plantar fasciitis) are:

There are many causes of heel pain other than plantar fasciitis; however, in my experience there is nothing else that presents with the classic symptom of significant pain that occurs with standing after a period of lying down or sitting.

It has been my experience that the longer a person with heel pain waits to receive medical care, the more difficult it can be for the treating physician to resolve the symptoms. This is primarily related to the length of time that the patient alters his or her gait to compensate for the pain. Eventually a new gait pattern will result from long-term compensation and becomes the new norm for the patient.

Walking on the outside of the foot while contracting the toes is common among people with foot pain. But this position will usually aggravate the pain by straining the plantar fascia, especially where it attaches to the bone.

Alterations in gait and stance caused by attempts to avoid foot pain will commonly generate secondary problems and pain in other areas. In fact, this new secondary pain may replace the heel pain as the most severe.

Secondary complaints of patients with heel pain can be one or more of the following:

Biomechanical examination of the lower extremity is essential to determine how the feet function in gait and stance and what changes have occurred in a heel-pain patient's gait to generate such symptoms as those listed above.

Classifying Pain

Heel pain can be classified into one of three categories: mild, moderate, or severe. To properly evaluate the degree of pain, the treating practitioner must use the thumb to aggressively palpate the origin of the plantar fascia at the medial tubercle of the calcaneus. Mild discomfort barely produces a reaction. Moderate pain produces retraction of the foot. Severe pain causes the patient to back up in the examination chair while retracting his or her foot.

I have outlined my treatment recommendations for the various degrees of heel pain, which have the consistent recommendations of supportive taping or an orthotic arch support and not walking barefoot at any time.

Treatment for mild heel pain:

Moderate heel pain:

Severe heel pain:

If a patient has allergies to local anesthetics, an oral steroid dose pack is a reasonable alternative. Ice massage can be performed to bare skin on a regular basis throughout the day and especially just before and after rigorous activities such as running. It is, however, of little value to ice through a strapping.

Gait Compensations

The longer people walk in pain the more likely they will compensate and the more difficult it usually is to return them to a normal gait. As long as the patient experiences significant pain in the heel, heel cups, orthoses, shoe modifications, and tapings are likely to be unsuccessful, since altered foot position will not allow supportive devices to be fully effective. The toes are usually dorsiflexed to hold the foot in an inverted or supinated position, which causes the patient to walk on the outside of the foot. This foot position also increases stretch on the plantar fascia, which aggravates the heel pain. Injection therapy should be performed without hesitation to eliminate this pain factor.

I recommend that patients who are prone to plantar fasciitis or Achilles tendinitis not walk-and certainly not run-barefoot on the beach. Soft sand will promote a negative heel position, which can be defined as the heel being lower than the forefoot when the entire foot is on the ground. While walking-and especially running-on the sand, the pounds per square inch at heel contact is increased three to five times compared to walking. This forces the heel into and below the sand's surface. Like walking uphill, running barefoot on a nonsupportive surface like sand will add significant stress and strain to the foot's ligaments, tendons, and joints.

Other important information concerning the biomechanics of a patient's foot, which can predispose the plantar fascia to overuse and subsequent irritation or microtears, should be obtained. Flexible flat feet and flexible cavus or high-arched feet are commonly associated with plantar fasciitis due to hypermobility. A tight or short heel cord or Achilles tendon will compromise the ability of the ankle to dorsiflex and therefore put additional strain on the plantar fascia as the foot dorsiflexes.

Evaluation of footwear can provide insight into possible poor foot mechanics. It is also important to ascertain from the patient what reduces the pain, such as heel elevation, and that should be incorporated into the treatment regime. The time a patient spends barefoot is extremely relevant since successful treatment will include eliminating most, and preferably all, barefoot standing or walking.

Remember, when patients state that they wear supportive shoes or orthoses "all day," they usually mean only at work or until they get home, where they quickly remove their shoes to walk on comfortable carpet. It is, of course, essential that supportive shoes and orthoses are worn until bedtime and, if possible, during nighttime visits to the bathroom or kitchen.

The importance of stretching the plantar fascia before standing cannot be overemphasized and is a key factor in the treatment and care of heel pain.

Exercise as Treatment

These exercises are performed while the patient is lying in bed and are essential to the overall treatment. Oral and written instructions should be given to the patient to dorsiflex the foot, stretching the toes toward the nose and holding that position for five to 10 seconds. Gradually increase the stretch of the plantar fascia by further dorsiflexing the foot over three or four attempts. The patient should try to bring the toes up as close to the nose as possible while keeping the legs straight. Pulling on a towel placed around the ball of the foot can be helpful in performing the exercise. Some discomfort may be experienced, or perhaps some slight burning in the posterior calf area as well as in the plantar heel. The patient then relaxes the foot and repeats this exercise, preferably eight to 10 times more. When performed properly, this exercise significantly reduces the symptoms when first getting out of bed.

Non weight-bearing stretching exercises are helpful to reduce severe morning pain. This is also an essential part of treatment. If this pain is not treated aggressively with stretching exercises, patients will alter their gait to avoid the pain. However, the pain should be reduced as a result of the non weight-bearing exercises, allowing patients to put their feet down in a normal or plantar-grade fashion as soon as they get up in the morning. Orthoses and supportive lace-up shoes should be worn at all times.

Supportive adhesive strapping applied to the foot, preferably with a supportive arch pad, will help to control, support, improve the mechanics of, and apply compression to the foot. Foot tapings or strappings are extremely valuable since they remain in place 24 hours a day for seven to 10 days and provide crucial arch support, compression, and immobilization. I highly recommend using elastic tape, skin adherent, and a 1/4-inch orthopedic felt arch pad to construct the taping, which must primarily be comfortable to the patient.

One of the greatest problems in treating heel pain is patient compliance. Using supportive tapings or strapping eliminates the compliance issue since they remain on the foot for a week or more, providing arch support 24 hours a day. Patients are never without arch support as long as the strapping stays on.

When applying strappings, it is my recommendation that a good skin adherent be used. I prefer an elastic tape to the non-elastic or non-stretch tape. I find the stretch tape extremely beneficial and more durable than the non-stretch tape. When people bear weight, considerable demands are applied to the tape, which leads non-stretch tape to fall off the skin within a day or two.

An appropriate felt pad is fashioned to fit the arch. The pad should have beveled edges and fill the longitudinal arch and transverse arch completely. Elastic tape is then applied under stretch to remove most of the stretch from the tape. By leaving some stretch in the tape it allows the foot to splay or expand under full weight-bearing without loosening of the tape or irritation to the skin. Taping should be performed when the patient is in a sitting or reclining position with the foot held at 90º to the leg in a semi-weight-bearing position.

It is also essential that the strapping be applied so that the loose ends are tucked in. Loose ends should be covered to prevent them from rolling or curling, which will lead to the premature removal of the strapping. Strappings should stay on the patient at least 10 to 14 days.

Arch pads should be made out of a good, 1/4-inch-thick, adhesive orthopedic felt. Each pad should be fashioned in a semi-elliptical shape to conform to the arch area. It should be skived or beveled at the borders to make it as comfortable as possible for the patient. The patient should not feel any significant ridges for which they may feel a need to compensate. Place the pad just behind the first metatarsal head at the border of the medial heel. The pad should also extend just to the medial border of the arch and does not need to extend up into the medial side of the foot.

When caring for strappings, the patient should secure a towel or washcloth around the ankle, then place a plastic bag over the foot and towel and seal the bag with something elastic to insure that minimal water gets into the bag onto the strapping. Proper care of the strapping is crucial to insure its longevity. Waxing the tape after application helps to make it water-resistant and prevents the loose edges from curling. Although the patient is required to keep the taping dry, relief of symptoms is an incentive.

Combining an injection to eliminate pain with a comfortable arch support incorporated in a compressive strapping to control pronation, thereby reducing strain on the plantar fascia, produces the desired effect of treating the symptoms and the cause of the pain at the same time. One injection with cortisone and a long-acting local anesthetic, along with a good supportive strapping, will produce 80% to 100% relief within one week in most cases. Eliminating heel pain with an injection plays a significant role in reducing the changes in a patient's gait.

Do not allow the displeasure of the patient who is receiving the corticosteroid let you rush your injection and compromise your and effectiveness. I recommend a 1-1/2-inch needle to allow penetration to bone and 25 gauge since plantar heel skin is firm and thick. Hold the foot firmly and the syringe like a dart. Penetrate the plantar medial heel skin, rapidly proceeding directly to bone immediately after the vapocoolant spray is stopped. This is usually the worst pain during the injection but it can be minimized with this technique. Care must be taken to inject slowly as the needle is repositioned on and off the plantar medial tubercle of the calcaneus, injecting a long-acting local anesthetic and the corticosteroid above and below the plantar fascia covering an area the size of a nickel.

Vapocoolant spray applied to the injection site is highly recommended before and during the injection to reduce discomfort. Despite any pain from the injection, patients will usually agree to a second injection and many times will ask for one if the first shot significantly reduced their pain. If relief is only temporary, patients will frequently hesitate to agree to another injection and many times will refuse it if suggested.

When the foot is taped or strapped, I usually recommend that the patient wear good supportive lace-up shoes, such as an athletic shoe. Patients should wear heel lifts at all times with the strappings. They are not to go barefoot. Of course, they should perform the non-weight-bearing stretching exercises. They should be fitted with prefabricated orthoses at either the first or second visit to replace the strappings that have been worn for a week or more. It is important that these patients do not go barefoot until they are treated successfully and remain asymptomatic for a good three to four months. When the weather is warmer, supportive sandals can be worn.

If a patient does not respond to the normal treatment regime, night splints worn when sleeping can be used to reduce morning pain. Again, it is essential to get these people off to their daily activities on a minimally painful foot, which will help to produce a better result overall.4

Second Stage of Treatment

Most patients should be 80% to 100% improved within a week's time with one injection and strapping. Patients within those percentages of improvement should begin to wear their orthoses, stay in good supportive shoes, keep up with the non-weight-bearing stretching exercises, and continue to not go barefoot. If the patient returns 70% to 80% improved, I recommend restrapping the foot, and then continuing with the rest of the protocol.

Applying a second strapping will help to insure that improvement will progress closer to 100% by the time the patient returns in two to three weeks. Prefabricated orthoses should be worn right after the strapping is removed and at all times when walking. It is crucial that these people at no time go barefoot.

Custom-fitted orthoses are recommended to those patients who do not achieve complete resolution from the prefabricated orthoses. Rigid or semirigid orthoses made of various synthetic materials will supply the necessary degree of arch support and other important modifications that a podiatrist can determine from his or her biomechanical examination.5

When patients return for the second visit and state that their improvement is 70% or less, I recommend a second injection. Again, the patient should be restrapped, continue with the nonweight-bearing stretching, not go barefoot, and have pain medication or NSAIDs prescribed. Although I seldom need to use narcotics for pain management, they are useful to assist in the reduction of heel pain.

Surgery to release the plantar fascia and remove a heel spur is necessary in only a small number of patients.6 Open incisional surgery or endoscopic surgery have risks and complications that include nerve entrapment, recurrent heel pain, infections, and enlarged and thickened scars.

It is my opinion that, unfortunately, too many patients have heel spur surgery due to what I believe is a lack of understanding of plantar fasciitis by practitioners. An inability to render patients asymptomatic with aggressive conservative measures leads rapidly, and many times unnecessarily, to surgery.

About 50% of heel spur surgeries are successful. These patients, however, in many cases will still need injections, strappings, and orthoses following the surgery, and may not be able to return to work for a number of months postoperatively.


References

By: John H. Walter, Jr., DPM, chair of podiatric orthopedics and medicine at Temple University School of Podiatric Medicine.

From: BioMechanics March 2001

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