Foot Pain: Down at the Heels

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Down at the Heels

by: Haran - healthology.com

Most of us take our heels for granted, until they start hurting. It is hard to

believe that heels can cause so much havoc, but it turns out that pain felt

under the heel bone—which works in collaboration with 33 joints and a

network of more than 100 tendons, muscles and ligaments—can bring the

most stoic person to their knees. Heel pain is one of the most common types

of foot pain, and podiatrists say they are seeing more people complaining of

it. The increase in heel pain rates is due, in part, to the aging population and

rising rates of obesity. But one of the major causes of heel pain is associated

with positive trend: More Americans are starting exercise programs. The

problem is that they often lack shoes with good arch support and don't

incorporate stretching into their regimen.

Below, Dr. Jensen, a member of the Board of Trustees of the

American Podiatric Medical Association (APMA) and a podiatrist in private

practice in Modesto, California, explains what causes heel pain, and how to

treat it.

How common is heel pain?

The APMA feels that there is an epidemic of heel pain afflicting this country.

Questions related to heel pain make up over 70 percent of the inquiries to

consumer hotlines cosponsored by the APMA and the USA Today over the

last ten years. Heel pain is probably one of the most common diagnoses that

we treat.

What is the most common cause of heel pain?

The most common cause of heel pain is a condition called plantar fasciitis,

which is inflammation of the plantar fascial ligament. The plantar fascial

ligament is a tight band of tissue that originates from the bottom of the heel

bone and spreads in a web like fashion to the pads of the toes. If this ligament

becomes " overworked " it can become inflamed and painful. The reason it's

most common to feel the pain underneath the heel is you have all the tension

being placed on that ligament concentrated in a very narrow area underneath

the heel bone itself. The pain can be experienced anywhere along the length

of that ligament: right underneath the heel, in the central portion of the arch,

or

less commonly out towards the ball of the foot.

What else contributes to heel pain?

Shoes that do not give adequate support to the foot are among the most

common causes of heel pain. Some of the new athletic shoes that are being

designed have large cutouts through the arch area, which causes the shoe to

flex at the midfoot instead of the ball of the foot, which is much more natural.

As a result, the plantar fascial ligament is overstretched.

We are also seeing street shoes that are more affordable but have less arch

support built into them. The shoe companies are saving money on the

construction of these shoes at the expense of the consumer. The lack of

support from the shoes results in an increased stress on the plantar fascial

ligament, resulting in inflammation of the ligament.

Exercise can be a risk factor if the patient is not training properly or is

using

equipment improperly. We're seeing people leading a much more active

lifestyle to improve their overall health, but if they're not stretching or

wearing

appropriate shoes, they can have heel pain. Being overweight contributes to

heel pain, because anything that makes the foot work harder during activity is

a risk factor.

Another large source of plantar fasciitis is a natural flattening of the arch.

It

has been my experience that this condition can strike women as early as their

20s and affects men in their 40s. As the arch begins to flatten, the ligament is

under greater tension and becomes painful. This flattening of the arch is

usually accompanied by an outward rolling of the heel, which results in a

motion called eversion, or the rolling of the foot inward (inversion). These

movements cause the arch to flatten and this results in an increased stretch

on the plantar fascial ligament, which causes the pain.

What is a heel spur?

A heel spur is a calcium build-up that can occur either on the back of the heel,

where the Achilles tendon attaches, or on the bottom of the heel that is closer

to the ground where the plantar fascial ligament originates from the heel

bone. As the ligament becomes pulled, the bone can become irritated and the

calcium begins to build up. It's important to remember the pain is usually

associated with the pulling on the ligament as opposed to the heel spur.

What does heel pain usually feel like?

There is a great deal of variability in how each patient feels the pain. The

discomfort can be anything from a dull ache under the heel commonly

referred to as a stone bruise on up to a sharp, shooting pain where the patient

is unable to walk on the foot at all. The pain can be most severe upon first

getting out of bed in the morning or after sitting for a period of time, or it

can be

mild in the morning and become progressively more severe with activity

during the day.

Who does heel pain affect?

Heel pain/plantar fasciitis can occur in children through the elderly. Plantar

fasciitis commonly hits in middle age as the foot matures and the arch flattens.

We see it in a lot in people who are starting new exercise programs,

particularly walking programs. They're not doing appropriate stretching or

obtaining appropriate shoes.

We also see heel pain in younger people who are more aggressive with their

exercise. People who spend long periods of time on their feet, such as hair

stylists, waitresses and sales people, are also at risk for heel pain at some

point in their life.

What can people do at home to ease their heel pain?

People with heel pain should inspect their shoes to make sure that they are

stiff through the middle portion of the shoe, also known as the shank, to insure

that the shoe isn't contributing to the problem. The shoe should have a

reasonably firm heel, so you don't get excessive rolling of the foot as you

walk.

Patients can also buy an over-the-counter arch support inner sole. You can

get arch supports either through your local sporting goods store or through

your pharmacy.

In addition to arch supports, people should try reducing their activity level,

applications of ice, stretching exercises and anti-inflammatory medications

that are available over-the-counter.

What kind of stretches do you recommend?

Most important is a stretch for the Achilles tendon. Many of us have jobs

where we're working sitting down, and even some of the athletes who are

very physically active sit down after they've exercised. As a result, the

Achilles

tendon becomes tight. This causes people to walk in such a manner that

leads to increased stretch on the fascial ligament. If you can stretch out the

Achilles tendon, many times you relieve your heel symptoms.

My personal favorite is a stretch where the patient places the ball of the foot

on the edge of a step with the heel hanging over the edge of the step. With a

straight leg, they simply allow the heel to lower and that causes the stretch on

the Achilles tendon. It's important not to force the stretch, just let it happen

very

passively and easily.

Are there particular kinds of exercise that are harder on the heel than others?

One of the types of exercise that has been a real problem is the treadmill. As

people begin to elevate the treadmill in order to increase their heart rates, it

increases the stretch on the plantar fascial ligament. It's not natural to walk

uphill all of the time. So if they are going to elevate the treadmill for

periods of

time, they should also lower it back down for a while.

At what point would you recommend someone see a doctor?

I think if they've tried the home therapies, and they haven't seen

improvements over one to two weeks, then they should be evaluated by a

podiatrist.

It's important to have heel pain evaluated because there are other sources of

pain other than just plantar fascitis. Nerve conditions that can cause pain

underneath the heel should be ruled out. Arthritic conditions, of course, can

cause pain under the heel, and some of the soft tissue inflammatory type

conditions can also contribute.

What would that initial evaluation involve?

Normally, the initial evaluation would include a physical exam of the foot,

making sure to isolate the source of the pain. It would also include X-rays to

evaluate the bone for any arthritic type conditions, fractures or the presence

of

a heel spur. Blood tests should be conducted if there are suspicions of

arthritic or soft tissue inflammatory conditions, such as lupus, to help aid in

the

diagnosis.

What do medical treatments usually consist of?

The first line of treatment is to try to reduce the inflammation by using

prescription anti-inflammatory medications and possibly a steroid injection.

Support of the foot and arch is the next concern and this can be accomplished

with a tape strapping of the foot, if the patient has no allergies to tape, and

custom orthotics or even a walking cast and crutches might be recommended

in cases of severe pain.

Physical therapy can also assist in the reduction of inflammation and the

promotion of healing. Physical therapy can include whirlpool, ultrasound,

electrical stimulation, application of heat or cold, as well as stretching.

When is surgery considered?

Surgery is always a procedure of last recourse. It has been shown that on the

average plantar fascitis resolves by itself over a year and a half. With the

majority of treatments available the doctor is just trying to help keep the

patient as comfortable as possible while the body heals itself.

But if all other things have failed, then surgery is certainly a consideration.

The purpose of the surgery, which is done on an outpatient basis, is to loosen

the portion of the ligament that is causing the pain in order to reduce the

pull.

The same surgery is performed if you have a heel spur. The spur is an

indication of that injury, but it's not usually the spur that's causing the

pain; it's

the ligament. There are procedures now where the spur is left in place and

only the ligament is released with resolution of pain being successfully

accomplished.

It is important to be careful with the surgery because you are dealing with the

main supporting ligament for the arch. Surgery typically keeps the patient off

their foot for two to six weeks, but I warn all patients that it could be a long

recovery. They could be restricted in their activities for up to a year after

surgery.

Are any other therapies available?

There is one new therapy called " extra-corporeal shock wave therapy. "

Extracorporeal shockwave therapy (ESWT) has been used since the early

1990s as an alternative to traditional heel surgery in certain cases of chronic

plantar faciitis. It was first approved by the FDA for the treatment of what is

known as chronic proximal plantar fasciitis in October of 2000. For patients

who have had plantar fascitis and heel pain that has not responded to

treatment, there is evidence that by using high-energy waves to treat the

tissues in that area, you can promote healing.

Many people are beginning to consider this as a last step before surgery. It's

done usually in an outpatient surgery setting or at a hospital because the

procedure normally requires anesthesia. The number of shock wave

procedures being performed has greatly increased in the past year, primarily

due to the effectiveness of the treatment, fewer complications and the

increase in availability of the technology.