A Step Ahead: What a Pain in the Heel
by Ralph J. Napolitano, Jr., DPM, CWSP, FACFAS
There are a handful of heel pain causes and cures. However, let’s zero in on the most common cause of heel pain, plantar fasciitis. The overwhelming majority of heel pain sufferers are afflicted with heel pain of this flavor. It’s a result of inflammation of a foot part called the plantar fascia. A bit of anatomy if I may. The plantar fascia is a flat band of tissue that is found just above your foot muscles on the bottom of the foot. It’s a ligament of sorts, that goes from the heel bone and fans out at the ball of the foot. What purpose does it serve? In reality, not much. To be very academic, it is linked to certain biomechanical functions as we walk and run, but neither you nor your feet would notice if it wasn’t there. However, when your plantar fascia is cranky and inflamed you bet you’ll know you have one..
Typical plantar fasciitis symptoms manifest as either a dull ache or sharp pain in the bottom of the heel. The pain is most noticeable with weight bearing after a night’s rest or getting up after being seated for a period of time. The medical term referring to pain that occurs after a period of rest is post-static dyskinesia. After we move around a bit, symptoms usually subside somewhat only to return later with more activities.
So how do we get plantar fasciitis in the first place? As referenced above, it’s an inflammation. It is usually the result of biomechanical issues in the foot and lower leg. Think of the bones of the arch as a bow, the kind of bow that shoots an arrow, and the plantar fascia as the bow string. If we could compress the bow instead of the bow string, we would get tension on the latter. So anything that causes pulling on the plantar fascia over time where it begins at the heel bone results in inflammation. Two big biomechanical foot issues that are linked to plantar fasciitis are flat foot architecture and a tight Achilles tendon. A tight Achilles is known as equinus. Without getting too detailed, this tightness doesn’t allow the foot to come up or dorsiflex past 90 degrees when we walk or run. What results is abnormal stress and inflammation on the plantar fascia. Over time, plantar fascia inflammation can cause the dreaded heel spur, a bony growth on the bottom of the heel. Is that a big deal? Not at all in this context. It’s merely a radiographic clue that inflammation has been present for a long time. Spurs in this anatomical area grow in a horizontal fashion and are not weight bearing in the traditional sense. Therefore, surgical removal of the spur is not necessary.
So how do we kick heel pain once and for all? Treatment should focus on this: breaking the cycle of inflammation and preventing it from coming back. Traditional ways to combat inflammation include drugs in oral form or injectable form. Oral anti-inflammatories include both nonsteroidal drugs like ibuprofen as well as true oral steroids. Of course steroid injections in the heel may seem daunting but work very well. Stubborn cases may require other modalities such as high energy ultrasound knows as Extra Corporeal Shock Wave Therapy (ESWT). We offer this non-surgical treatment at OrthoNeuro and it can be an excellent alternative to traditional surgery. Biomechanical ways to combat plantar fasciitis include arch supports, either over the counter or custom, as well as a night brace to help gain flexibility in cases where the Achilles tendon is tight. Physical therapy which may include traditional ultrasound can be helpful as well to break the cycle of inflammation. Going barefoot has it’s benefits since being unshod allows your foot muscles to work naturally. However, for plantar fasciitis patients, supporting the arch is necessary to break the inflammatory cycle so keep that in mind. You can engage in more shoeless activities as symptoms resolve. Finally, if all else fails there are surgical options. Releasing part of the plantar fascia, known as a plantar fasciotomy, is very effective. For those patients with an equinus problem (tight Achilles tendon), surgery to address this condition may be necessary to get rid of plantar fasciitis once and for all.
Hope to see that spring in your step!
Dr. Napolitano is a double board-certified podiatrist and wound care specialist physician. (CWSP). He specializes in medicine, surgery and wound care of the foot, ankle and lower leg. He was the first podiatrist in the state of Ohio to earn the board certification Certified Wound Specialist Physician (CWSP). Areas of special clinical interest and research include: general podiatric medicine and surgery, wound care and healing, diabetic limb preservation and surgical limb salvage, digital joint replacement and preservation surgery in the foot, lower extremity dermatology and infectious diseases, custom foot orthotics, gait analysis and athletic shoe gear consulting, aesthetic podiatry and laser care.