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Heel
pain is one of the most common reasons people see their
orthopaedist. A
busy general orthopaedist may see several cases of heel pain
each week or even each day.
Although the patients come from a variety of backgrounds
including athletics, the etiology is usually similar.
There
are several different disease processes that can cause heel
pain, but by far the most common is called plantar fascitis
(PF).
The
plantar fascia is a fibrous band of tissue that runs fairly
superficially from the heel bone to the ball of the foot.
As it courses along the foot, it widens as it approaches
the ball. The
function of the plantar fascia is to help maintain the normal
bony architecture of the foot.
Knowing
that the plantar fascia covers a majority of the bottom of the
foot, an astute observer might ask “why does inflammation of
the plantar fascia produce pain only at the heel?”
The answer lies in the distribution of the fascia.
It begins at a common spot on the heel bone and spreads
out to attach to various locations across the ball of the foot.
It therefore stands to reason that the weak link in the
chain is at the common origin where the width of the fascia is
minimal.
Many
athletes are affected, especially the slightly older athlete.
PF is common among runners, walkers and other athletes
but many suffers come from non or minimally athletic
backgrounds.
Roughly
twice as many women get PF as men.
Since much of the elasticity of many heel structures
decreases with age, the incidence of PF increases with age.
Being
overweight increases the likelihood that one will develop PF.
Also, the symptoms of inflammation may be more severe in
the overweight patient.
Inflexibility
can also lead to the development of fascitis.
The calf muscles attach to the heel bone via the achilles
tendon. If this
connection is relatively taught, the heel structures are
stressed and PF can develop.
Only
20-30% of PF is bilateral (on both sides).
It is believed that many of the bilateral cases are due
to a metabolic rather than a physical cause.
However, the treatment is still the same.
The
primary symptom of PF is heel pain.
The pain can be especially intense upon awakening or when
rising from a resting position since the first few steps stretch
the plantar fascia. The
pain may initially subside only to become worse as the day wears
on.
Approximately
95% of patients can be cured using conservative measures.
The first of these is a heel cup.
The purpose of a heel cup is two fold.
First, it provides either a physical or mechanical
cushion for the heel. By
compressing the soft tissue of the heel, it reduces the
mechanical stress placed on the bone and fascia.
Also, it lifts the heel slightly which can effectively
reduce mechanical stress.
Also,
patients are instructed to stretch the heel cord. Stretching consists of placing the hands on a wall with one
knee straight and back and one knee bent and forward(see
figure). The
patient should then bend forward so that tension is placed on
the calf muscles. The
stretch should be held for about ten seconds and repeated 20
times. It is good
to stretch both legs even if only one heel is painful.
Icing
the heel for 20-30 mins following activity has helped some
patients. Also,
moist heat and/or chemical heat (Flex-All 454) prior to activity
may be helpful.
Most
patients who can tolerate oral anti-inflammatory medications are
given a prescription to help alleviate the symptoms of PF.
If,
after several months of conserative therapy, little or no
progress is seen, a steroid injection into the heel may be
considered. This serves to calm the inflammed area and facilitate
healing.
Occasionally,
in about 2-3% of patients, a small surgical procedure may be
necessary to correct PF. The
procedure is known as a plantar fascial release.
The vast majority of people who progress to the point of
needing surgery are quite pleased with the outcome of the
procedure.
If
you have PF, be patient. Whether
managing the problem conservatively or invasively, a cure may
take some time. The
good news is that virtually everyone with PF is eventually
cured.
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