Heel pain is one of the most common issues that we treat of the foot & ankle. Something currently being observed in our office is a significant increase in the amount of heel pain we have been treating over the last few months. We believe this has to do with a couple of different factors. First, with many of us working and spending more time at home, people are more prone to walk barefoot or in unsupportive shoes. Second, people are also looking for new ways to get out of the house more by picking up activities such as running and hiking without the necessary preparation. While there are a number of different causes of heel pain, today we will focus on the most common cause, plantar fasciitis.
Plantar fasciitis
Plantar fasciitis is defined as inflammation to a ligament in the bottom of the foot known as the plantar fascia. This ligament attaches at the heel bone and expands outward, supporting the arch of the foot. Inflammation occurs when this ligament is abnormally pulled or stretched, creating small tears that become inflamed. When walking, the inflammation is unable to settle, however when the person is non weight bearing for a period of time, like when in bed or sitting in a chair, the first step is extremely painful as they are stepping on large amounts of inflammation. This is the hallmark sign of plantar fasciitis, known as post-static dyskinesia.
Diagnosis and treatment
Diagnosis of plantar fasciitis is based on a thorough history from the patient as well as physical exam. Imaging studies such as x-rays and ultrasound are also useful and are typically available at the podiatrist’s office. Further imaging studies may be required such as an MRI or CT scan.
Once diagnosed, a treatment regimen is set in place. The goal is to immediately treat the pain, as well as prevent the pain from recurring in the future, which is a common occurrence with plantar fasciitis. The following five-step plan may be the first line of action in treatment:
- Stretching exercises / ice- Your physician will provide you with some simple at-home exercises and stretches to decrease the tightness of the plantar fascia. Additionally, an ice massage to the area decreases inflammation.
- Steroid injection - Injecting medicine directly onto the plantar fascia will provide pain relief as well as directly controlling the inflammation to the area.
- Proper shoe selection - Not all tennis shoes are made the same. Furthermore, a higher priced shoe does not equal a higher quality shoe if the type of shoe selected is incorrect for your foot type. Your physician will guide you based on your physical exam to the appropriate type of shoes that should be worn based on your foot type and daily activities.
- Shoe inserts - Regardless of the type of shoe purchased, the inserts included are usually not high enough quality. They tend to be flimsy and lack the proper arch support to protect the plantar fascia. Based on your physical exam, your physician will recommend the proper shoe inserts that should be worn in the properly chosen shoes.
- Night splint - This device is administered by your physician so that while you sleep, the device holds the plantar fascia in a fixed position overnight to promote stretching, decrease inflammation to the area, and decrease that initial pain in the morning when getting up from bed.
While this treatment regimen is typically successful, treating a part of the body that is under constant stress from walking can be difficult. There are occasions where additional treatment, as well as advanced treatment options are necessary. Below are five common treatment options:
- Physical Therapy - Sometimes additional stretching and exercises are needed at the guidance of the physical therapist. Their specialty allows them to directly manipulate the plantar fascia with different modalities to improve the current pain as well as preventing long-term pain.
- Custom orthotics - When over-the-counter inserts are not providing enough support, your physician may recommend upgrading to a pair of custom orthotics. These are made from taking a mold of your foot in the office which is then sent to a lab and a personalized pair of inserts are made specifically for your foot.
- Medications - Certain medications such as pain relievers (Advil, ibuprofen, meloxicam) or oral steroids (methylprednisone, prednisone) may ease the pain and inflammation caused by plantar fasciitis and be a good addition to your treatment regimen.
- Immobilization - Sometimes the plantar fascia is too inflamed for treatment to be given while you continue to walk. After multiple failed treatment courses, immobilization is sometimes the best next option. This will be done by either placing your foot and ankle in a walking boot or applying a cast. The time of immobilization can be anywhere from 4 to 6 weeks.
- Surgery - When all other treatment options have failed, or there has been no improvement over the course of at least six months, this is the time when surgical intervention is considered. The procedure typically involves a small incision or two to the heel. Then a proportion of the plantar fascia is released from the heel bone. If a heel spur is present this will also possibly be resected from the heel bone. Recovery from the surgical procedure ranges from 4 to 6 weeks.
While plantar fasciitis is the most common cause of heel pain, there are still a number of other conditions that can cause the same symptoms, some more significant than others. If you or someone in your family is experiencing heel pain, please request an appointment with us – we will get you back on your feet!
