Heel Pain Syndrome

Heel Pain Syndrome

Your Marvelous Heel…!
Your heel is not a simple structure. It is a region comprised of a variety of body tissues. Thickened skin covers a unique network of shock-absorbing fat tissue. Below this is a binding-layer called the plantar fascia, which is attached to the heel bone. From this binding layer and the heel bone arise the origins of several important muscles of your foot. Your heel bone itself is covered by a special tissue layer (the periosteum); this layer helps feed and repair the body of the bone. Among these tissues and tissue layers, blood vessels and nerves course to more distant sites, both above and within your foot. Also, your heel bone is composed of a network of bone, a hard and thin shell of bone, and several joint surfaces on its hidden, irregular top surface (below the ankle bone). All of these special tissues are supposed to be arranged in a very specific, normal pattern (anatomy) so that they (and your foot, leg, etc) function properly (biomechanics).

Is your heel your ‘Achilles heel’?
Your heel tissues have their own qualities, strengths and weaknesses. Each of your tissues can be DIRECTLY injured, inflamed or infected, either singly or in combination. Also, your heel can be INDIRECTLY affected by your body’s general chemistry, hormones, and immunological system. The heel can be the target of more distant elements and functions of the skeletal system, blood system, nerve system, infections, and circulating toxins. If your foot anatomy is not properly arranged, either by birth or acquisition, the heel can suffer. If it suffers, you suffer.

Under the microscope (so to speak)
Your podiatric physician (podiatrist, a.k.a. foot doctor) realizes that any or some of the above tissues could be the site of your heel pain. Your podiatrist also realizes that one or more distant factors could be the origin of your symptoms (pain, burning sensation, etc.) And, your podiatrist has been trained to recognize abnormal foot and leg anatomy and to recognize their abnormal workings (pathomechanics or dysfunction) all of which would cause your heel symptoms. 
Sometimes it is necessary to test and examine several of these systems to find the answer to the question: why does my heel hurt. Once we learn where the problem is, a thorough discussion of how and when the problem began leads to questions about your current and past health history, current medications, allergies, surgical history and other factors. A review of your lifestyle and environment at home or work may disclose a situation which allowed the development of your problem heel. Questions may also be raised about problems above the heels, such as involving you knees, hips and back. Medical (systemic) conditions from which you suffer may also shed some light on the cause of your heel pain. Occasionally, laboratory blood tests are ordered to rule out (or in) some of these  systemic” (total body) conditions. X-rays of your foot or feet are then taken to rule out some of the more infrequent causes of heel pain, such as fractures, bone cysts, infections, a foreign body in your heel or deformities of the heel bone. Sometimes a heel spur is located (more about that later) under and / or behind the heel bone.
A clinical examination is vital to gain a more comprehensive picture of how your heel is being used by the rest of the body as you stand, walk and perhaps run. The point of maximum pain (if there is one) is located and appreciated. The alignment of the mechanical sections of the foot to each other is evaluated. The configuration of your arch both on and off of your feet is evaluated. The position of your heel in stance and gait is observed. The foot and leg are checked for excessively tight (contacted) or loose tendons and for spastic or loose (flaccid) muscles. The mobility of the tendo Achilles (heel cord) is carefully checked. We observe you as you walk during gait analysis. Sometimes very sophisticated video and force-plate analyses are ordered in difficult or critical performance situations. Only then can a plan of treatment be formulated and pursued.

Sorting it all out… 
Professional experience has taught us that the most common cause of heel pains is from mechanical forces. This could be a blunt blow to the soft tissues under your heel. However, more likely, it is repeated, excessive traction of the plantar fascia on the heel bone that most often causes an inflammation at their junction. Inflammation and pain of the plantar fascia is the result: plantar fasciitis (yes, there are two “i’s” together). This can be classified as a type of repetitive stress injury, RSI, that is an overworking of a part of the body, repeatedly. Not only can both the bone and the fascia (tendon-like tissue) be inflamed, swollen and painful, but so can the adjacent muscles and fat tissues. If persistent, these forces can cause the formation of a secondary bony spur under the heel. (More often than not, the heel spur is NOT the cause of the heel pain; it is just a scapegoat for the somewhat too eager surgeon. It is usually the inflammation that causes the spur, not the other way around!) Micro-injuries in these tissues can lead to a long recuperation in the absence of adequate rest, control and treatment (or even re-injury).

Down and out with Pronation
The chief cause of excessive plantar fascia-to-bone traction is a surplus of pronation (a complex movement within the foot, ankle and leg). Normal pronation allows your foot to become more mobile so that it adapts to the ground as you walk. There are certain architectural foot and leg    arrangements which force the foot to pronate more severe- ly than others. If your foot has one of these less than desirable arrangements, you are more likely to overwork the tissues in your foot and leg; you might then develop heel pain from plantar fasciitis. Plantar fasciitis is more likely to occur if you have normal to higher than normal arches. (People with very flat feet infrequently develop plantar fasciitis because their joints have already changed shape and alignment.) Being overweight (and a high percentage of American’s ARE) adds to the load and stresses in your feet, particularly your heel and forefoot. Certain shoes can allow or force your foot to pronate too much at a time when they should not.

Your Podiatrist to the Rescue
It is your podiatrist’s task to examine you and sort this all out, then make recommendations for your care. If symptoms and findings suggest that a medical problem is a significant component of your heel pain syndrome (group of symptoms and signs), then you will be referred back to your primary care physician (PCP) or some other specialist (e.g. rheumatologist), while your podiatrist manages the local manifestations. 
If mechanical forces are to blame, the treatment must focus on relative resting of the foot and the long-term control of them. Mechanical control can include the use of:

  • special stretching exercises,
  • night-time bracing of the leg, ankle, foot,
  • a change in your work style, duties and environment,
  • alternative recreational activities,
  • knowing which shoes to wear and to avoid,
  • body weight reduction via MD supervision,
  • Custom-made functional orthotics (for the best control of your foot function).

Of more immediate importance, an effort is made to reduce your suffering as quickly as possible. Such symptomatic relief can include the use of:

  • specific shoe modifications,
  • specials inserts, lifts or padding,
  • repeated taping or strapping of the foot,
  • pain-blocking with ice massage,
  • NSAID (non-steroidal, anti-inflammatory drugs) for pain relief too,
  • steroid injections (for quick reduction of localized pockets of inflammation),
  • ultrasound physical therapies (a form of deep warming of the injured tissues),
  • Manipulation and massage therapy.

What if….
Heel pain syndrome from mechanical causes can be so significant that it may take months for good control, healing and reduction of symptoms. If and when it becomes apparent that there is still insufficient relief, then additional testing and consultations may be required. If after many months the heel is still very much a problem, and IF the patient has complied with all other recommendations (including weight reduction), then you still have two options!

  • The OSSITRON (r)Option:

Using focused soundwave technology, similar to that used during the non-invasive treatment of painful kidney stones, some podiatric and orthopaedic doctors have had success in reducing chronic, otherwise intractible heel pains with “shockwave” therapy. Though the way it works is not clearly understood, the focused-sound shockwave treatment has been found to be helpful in reducing or eliminating heel pains when conservative treatments have failed. Though usually performed in an ambulatory surgical center, no incision or cutting is performed. Your podiatric physician can provide more details.

  • The Surgical Approach :

Under certain circumstances, it may be appropriate and necessary to consider surgical intervention. Only about 1 person in 20 (5%) with persistent heel pain even becomes a candidate for this invasive surgery. This can include elements to free up trapped nerve(s), release of the plantar fascia (partial or complete), and removal of any associated heel (bone) spur, or other deep surgical techniques. This is usually consider the technique(s) of last resort since recuperation can be prolonged (many months) and complications may develop while the foot is trying to heal and the body re-adjusts. Even with detailed, evaluations preoperatively, in this case, getting a second opinion from a qualified professional is a good idea (and not from some otherwise, well-meaning neighbor or friend).