Foot Pain in Heel Bone

  • Foot pain in the heel bone can be usually due to the development of a heel spur.
  • A heel spur should essentially be treated as if though it were plantar fasciitis.
  • Plantar fasciitis is the most common cause of heel pain seen by foot and ankle surgeons.
  • -Massive pain that inhibits you from standing
  • -About 15% of the population suffer from plantar fasciitis.
  • -This is usually an overuse injury at the origin of the plantar fascia caused by excessive stress to the foot or  biomechanical abnormalities of the foot.

    Heel Spur
    Heel Spur

Anatomy

  • -The plantar fascia stretches from your heel (calcaneus) to the joints of all your toes (Metatarsal phalangeal joints)
  • -The plantar fascia consists of 3 bands: medial, central, and lateral.
  • -Usually the medial band is damaged, but it can also be the central band.
  • -The plantar fascial bands are supplied by the medial and lateral plantar nerves.
  • -The thickness of a normal plantar fascia is approximately 3 mm.
  • -In patients with plantar fasciitis, the maximum thickness is significantly increased to 7 mm

Definition

  • -Plantar fasciitis is described as a painful inflammatory process.
  • -generally at the origin of the plantar fascia on the calcaneus.
  • -It can also be central in the plantar arch.
  • **It is very uncommon for plantar fascia pain to be on the outside of your foot or toward the toes.

Risk Factors

  • -40 to 60 years
  • -more common in women
  • -High Arch and Flat Foot
  • -Occupations that require standing
  • -Common in athletes, nurses, mailmen, factory workers, mechanics etc
  • -People with footwear that is loose & has no arch support.
  • -Obese patients -this leads to chronic stretching & degeneration & pain.
  • -Pregnant patients- the ligaments get loose and stretch
  • -Tight Calf muscles

Symptoms

  • -Pain is usually localized to the medial calcaneal tubercle
  • -Initially pain is sharp and worse with the first step of the day after a period of non–weight bearing.
  • -Chronically it is dull and painful over time

 

Diagnostic testing

  • Radiographs(X-rays) – Check for a Heel Spur- this is bone formation at the insertion of the plantar fascia- Note: this is not what causes the pain- but correlates the diagnosis
  • Ultrasounds- Inflammed fascia is normally hypoechoic- but normal fascia is normally iso-echoic
  • MRI- The best method- but almost never needed (highly overkill)

 

Non-surgical Treatment

 

Low Dye Strapping

  •  I love this type of taping- it holds the foot in an ideal structure and re-inforces the arch for a couple days until the inflammation of the fascia can die down.
  • Tip 1: ***If low dye taping does work for you- In my experience an orthotic will complete cure your heel pain the majority of the time***

Get the right shoes

  • Tip 1: ***Get atleast a 1 inch heel on your running shoe – according to the Podiatric Sports Association***
  • Tip 2: ***Make sure the shoe bends in the front and not in the middle or the back of the shoe**
  • Tip 3: ***Avoid sandals & going barefoot on hard surfaces**

Stretching of the Achilles Tendon and Plantar Fascia

  • Tip 1:***Studies show that stretching your achilles tendon 3x per day for 2mins at a time will cure the pain in 25% of
  • people***
  • Tip 2:**Stretching your feet(the plantar fascia) as well as the Achilles tendon boosts that number from 22% to 55%
  • according to studies!*** So start stretching immediately!
  • Tip 3:***Use night splints to stretch your feet for you while you sleep!***

Night Splints

  • Wear these at night to keep your feet stretched (the toes point straight rather than down when you sleep)
  • Tip 1: ***Studies show that night splints helped almost 100% of patients***
  • Tip 2: ***Ease into them while napping, you forget you are even wearing them after 1-2 naps!***

Physical Therapy

  • Studies show good relief after 2-4 weeks when combined with anti-inflammatory medications & ice.
  • Ultrasound & whirlpool therapy also helps greatly.
  • No exact numbers available from studies.

Anti-inflammatory Medication:

  • Take a 2 week regimen of regular advil, Ibuprofen or any other NSAID(see pharmacist for dosing).
  • Watch for allergies.
  • Topical NSAIDS are frequently helpful- but no exact numbers are available from studies.

Injection of Corticosteroids:

In my experience- **this is the gold standard for immediate relief!** Fixed with a 5 minute visit to the podiatrist.

  • Tip 1:***Studies show almost all people recieve temporary relief that last for up to 6-8 weeks, in about 25% it never comes back***
  • Tip 2: If you remove the cause during the pain-free injection period(6-8weeks) then the pain should never come back.

Orthotics

***The long term Gold Standard- whereas corticosteroids are the short term gold standard***

  • Tip 1: ***Orthotics combined with anti-inflammatories & Injections have an 85% permanent cure rate for plantar fasciitis! Compared to just 30% without orthotics***
  • Tip 2: Get some arch supporting orthotics like PowerStep (25$) not the gel inserts of Dr. Scholl – they just cushion but not support the arch.
  • Tip 3: Get some heel lifts if you can over Dr. Scholl, but PowerSteps are better than both.
  • Tip 4: Powersteps > Heel Lift > Dr. Scholl Gel inserts

Extracorporeal Shock-Wave Therapy
Sound waves are propagated to damaged tissues to induce microtrauma.This microtrauma stimulates healing by attracting blood vessels and nutrients to the plantar fascia.

  • Tip 1:*** Used as a last ditch effort before surgery if you are rich- because it is not covered by any insurance***
  • Tip 2: I say avoid it- its expensive and unproven!

Surgical Treatment

Studies show that only 5-10% of people will ever need surgery on their Heel for Plantar Fasciitis.

Open Plantar Fasciotomy

  • -Open plantar fasciotomy allows for release of the tight plantar fascial bands.
  • -Studies show that this surgery is 37% effective with a fascial release only & 45% successful in curing with fascial release as well as removal of the bone spur.
  • -Most do experience relief-

Endoscopic Plantar Fasciotomy ***Great choice***

  • -Popular due to minimally invasive nature.
  • -Minimizes complications and recovery time compared with open procedures.
  • -A scope is inserted through a very small incision and the fascia is resected.
  • -Satisfaction ranged from 60% to 80% with this procedure in relief of heel pain.

Cryosurgery

  • -Percutaneous cryosurgery uses subfreezing temperatures to produce analgesic effects.
  • -Nerves are detected & frozen for 3 mins, then thaw for 30 seconds & repeated.
  • -Numbness will occur for many months.
  • -Research shows 78% success – but more research is still needed for this procedure.

Radiofrequency Nerve Ablation

  • -Another minimally invasive procedure that ablates the nerve with an electrode through the skin.
  • -Patients are allowed to bear weight immediately after the procedure.

Coblation Therapy

  • -Coblation therapy with Topaz is a form of bipolar radiofrequency.
  • -causes microscopic damage to the fascia, which increases the blood supply to the fascia; this causes it to rebuild and flood the area with growth factors.
  • -Patient shouldn’t walk for 3 weeks.