F*@king Heel Pain! I chose heel pain as my first post because it seems to be one of the most common causes of visits to the doctor’s office. And not only is it common, but it’s also the most frustrating…
“I’ve been struggling with pain at the bottom of my heel for over a year. It started spontaneously one day after a weekend at an amusement park with my family and it hasn’t gone away. It seems to be worse as soon as I stand up, especially in the morning. I don’t remember injuring my foot. I’ve seen so many doctors and I’ve done literally everything: expensive inserts, anti-inflammatories, steroid injections, and the dreaded frozen water bottle. Nothing works and now these doctors think I’m using this condition as a way to get pain meds!” – Taylor, 38 years
Taylor’s story probably sounds familiar to many of you; heel pain that just won’t go away despite what you do. You’ve been evaluated by all the doctors within your network and you’ve been a good patient and followed the treatment regimen, but your heel pain won’t go away. Ughhh!
The most common cause of heel pain is Plantar Fasciitis. Plantar fasciitis is inflammation of the plantar fascia, a thick band of tissue that extends from the heel to the toes. It affects men and women equally. Plantar fasciitis is not commonly due to trauma, rather the inflammation usually begins as a result of overuse. That said, there are some factors that place people at higher risk such as obesity, tight calves, and high endurance weightbearing activity (i.e., running).
The gold-standard treatment for plantar fasciitis is non-operative. Your treatment regimen should include multiple options. To get the most out of your treatment plan, it should include a dedicated physical therapy regimen, one or more anti-inflammatories (oral, topical and/or injectable) and orthotic devices (heel cushions, night splints). Patients often want to know what type of inserts to buy. My answer: the cheapest one that works for you is the best one. An expensive custom insert that doesn’t work is obviously inferior to a relatively cheap over-the-counter insert that lowers your pain. In fact, a study by Pfeffer et al (https://www.ncbi.nlm.nih.gov/pubmed/10229276) concluded that “when used in conjunction with a stretching program, a prefabricated shoe insert is more likely to produce improvement in symptoms as part of the initial treatment of proximal plantar fasciitis than a custom polypropylene orthotic device.”
With an abundance of patience, plantar fasciitis will often go away. It may take months of following a non-operative treatment routine, but it will usually resolve. DiGiovanni et al (https://www.ncbi.nlm.nih.gov/pubmed/16882901) showed a high rate of improvement at two months following a plantar fascia-specific stretching program. Considering this, surgery for plantar fasciitis is usually reserved for unruly cases that fail non-operative treatment for over nine to twelve months.
Let’s say it’s been a year and you’re thinking about more serious options. Surgery for plantar fasciitis will include a release of part of the plantar fascia. This is called a partial plantar fasciotomy. The surgeon might also include a tarsal tunnel decompression to decompress one of nerves in the foot and ankle. A procedure to correct calf tightness might also be indicated. There are various ways to accomplish this depending on the cause of the calf tightness. If you’ve already had surgery and your symptoms are not improved, you should consider a second opinion to investigate the cause. Although plantar fasciitis is the leading cause of heel pain, it is not the only cause of heel pain.
Additional causes of heel pain can include:
• Tarsal tunnel syndrome or Baxter’s nerve impingement
• Calcaneal stress fractures
• Soft tissue masses
• Bone lesions
• Plantar fascial tears
• Insertional Achilles tendinopathy
• Tendon tears
• Various systemic inflammatory conditions
Your work-up should include a thorough history, physical exam, weight bearing plain films, additional advanced imaging as indicated (such as an MRI or CT scan). An ultrasound is useful to diagnose problems that are best seen when the foot is in motion, such as tendon stenosis or an accessory flexor tendon.
If you’re frustrated by your persistent heel pain, I recommend contacting Vivien Health. We have the world’s top specialists to evaluate your foot and ankle problems.