Heels That Hurt
Whether you are a regular runner, a weekend warrior, or someone knocking around the yard, foot problems can easily cause you pain. Most pain associated with the heel can be tied to one disorder: plantar fasciitis.
"There is a ligament called the plantar fascia which attaches at the heel bone and then runs through the arch and into the toes," explains Lowell Scott Weil, Jr., DPM, team podiatrist for the Chicago White Sox. "Its function is to support the arch in an arch position. If you bend your toes back, you can feel a tight band in your arch. That is the plantar fascia."
Forces acting on the foot while walking or running cause the arch to flatten out. At the same time, the plantar fascia is trying to keep this from happening. These opposing forces put tremendous stress on the tissue. When enough continuing stress exceeds the body’s ability to heal itself, the tissue under the heel becomes injured and painful.
The symptoms of plantar fasciitis include severe pain, especially first thing in the morning. Most people say that it hurts from "the instant their heel touches the ground." Some even feel pain and stiffness when starting to walk after sitting for a while.
Plantar fasciitis is often seen in persons over 40 years old or in those who are overweight. There is also an increase in visits to doctors during the spring and summer months as people resume activities involving walking or running. Among runners and other athletes, shoes that do not support the foot properly commonly lead to plantar fasciitis.
"We see a lot of shoe gear problems, especially with runners," notes Douglas Hale, DPM, a podiatrist in the Seattle area. "However, bad shoe selection also can cause heel pain in people who walk for exercise or who are on their feet a lot in their jobs. It should be stressed that price alone is not an indicator of quality in shoes."
He suggests three things people should look for in a shoe (whether they be walking or running):
- Hold the back of the shoe where your heel is located and try to squeeze the two sides together. If there is a sufficiently firm heel counter, you will not be able to collapse it.
- Take the toe of the shoe and bend it up toward the heel. The shoe should bend at the front, not in the middle. If it bends in the middle, the shoe is too flexible and will not provide enough support.
- Put one hand on the heel and the other on the toe. Twist the shoe like you are trying to wring out a towel. The less you can twist it, the more support there is for your foot.
If proper shoes are needed to prevent heel pain, it stands to reason that lack of shoes could contribute to a flare-up of plantar fasciitis. Going barefoot, even just around the house, can cause or prolong heel pain. The same is true of slippers and sandals, because they have so little cushion or support.
Another good preventive measure is stretching exercises 2-3 times a day. Place one foot behind you and lean forward keeping your knee stiff. Hold that position for 15-20 seconds, then switch. Repeat this on each leg at least three times per session.
"I don't think the importance of stretching can be over emphasized," stresses Dr. Weil. "Even if you don't have heel pain, you want to maintain some kind of daily stretching routine. These should be done before exercise and absolutely afterwards."
Diagnosis is most often made by assessing the place (middle of the bottom of the heel) and timing (early morning and after prolonged sitting) of the pain. The doctor will also question you on your activity levels and your weight. Other causes of heel pain are very rare; estimates of more than 95% of all heel troubles resulting from plantar fasciitis.
While fractures, infection, and arthritis can also occur, the place and timing of the pain is usually different. Sometimes an x-ray or other imaging test is needed to exclude these other causes. Even in people without heel pain, the x-ray often shows a “bone spur” where the plantar fascia attaches to the heel.
"When it comes to actually treating heel disorders, the importance of good shoes cannot be emphasized enough," urges Dr. Hale. "The first thing that needs to be done is to make sure your footwear is appropriate, and that it is worn all the time." For many heel pain sufferers a switch to good shoes may be all that is required.
Both podiatrists suggest getting a good over-the-counter shoe insert that can support the arch and raise the heel. While custom-made orthotics provide the most accurate way to direct the foot into the correct position for walking or running, they are often not necessary as a first line treatment. "I would say about 80% of my patients respond favorably to over-the-counter inserts," notes Dr. Weil.
Other suggested treatments include:
- Purchase shoes with higher heels on them. Elevating the heel relaxes the tight structures in the foot.
- Put ice on the heel for 20 minutes, three times a day. Studies indicate that ice water baths or ice directly on the skin may be the best way to get cold directly to the deep tissues involved. Other options include special Blue Ice gel packs available at most pharmacies and many running supply stores. Frozen peas or corn may also work, but they won't stay cold as long.
- Use a non-steroidal anti-inflammatory medication, such as aspirin, ibuprofen, or naproxen. Follow the directions on the label or those given by your doctor.
- Avoid activities that cause a pounding of the foot. Bicycling and swimming are good alternatives for exercise during this time.
- If the pain is not gone within 7-10 days or becomes so bad you have trouble walking, seek out a podiatrist or an orthopedic physician who is a specialist in the treatment of heel pain.
Stretch Splinting and Other Options
In a number of studies, “stretch splinting” at night has proven to be quite effective in improving symptoms and reducing the duration of activity limitation. When splinting is not effective, doctors may prescribe custom orthotics based on molds taken of your foot while not bearing any weight.
Other treatments could include steroid injections in the heel, physical therapy, splints used to keep the foot straight while sleeping, or a cast to keep the foot immobilized. Newer treatments include electrical application of medication and shock wave stimulation of the plantar fascia.
Left untreated, the bone of the heel can begin to grow toward the inflamed part of the plantar fascia. This bone or heel spur is treated conservatively in the same manner as the fasciitis.
Should surgery become necessary, there are three methods. In all three, the plantar fascia is cut or released from its attachment to the heel bone and then eventually reattaches itself in a lengthened position.
- In endoscopic surgery, the plantar fascia is cut using a tiny camera to see the ligament. This requires only two small incisions and allows for a much quicker return to normal activities.
- Open heel surgery involves cutting the plantar fascia through a surgical incision. This is mainly used for problems that recur following endoscopic surgery. Sometimes a growth on the heel may be seen. This kind of procedure is often used to remove the spur and release the plantar fascia at the same time.
- The final method of surgery is performed without a camera and under a local anesthetic. In this procedure, a single small incision is made and the fascia cut. It is less expensive and should have fewer complications.
Drs. Hale and Weil agree that surgery should not even be discussed as a first line therapy. "Conservative treatment is effective more than 95% of the time, allowing the person to avoid surgery," says Dr. Hale.
"Some people say surgery could be considered if these other methods don't work within six months. Since there is research showing that people may take nine months or more to get better, we usually suggest waiting a year before considering surgery."
American Orthopedic Foot and Ankle Society
Foot and Ankle Center of Washington and Arch and Heel Pain Clinic
Canadian Podiatric Medical Association
Podiatrists in Canada
Heel and arch pain. Foot and Ankle Center website. Available at: http://www.footankle.com/heel-arch-pain2.htm. Accessed September 4, 2008.
Plantar fasciitis. EBSCO Health Library website. Available at: http://www.ebscohost.com/thisTopic.php?marketID=15topicID=81. Updated November 2007. Accessed September 4, 2008.
Last reviewed May 2008 by John C. Keel, MD
Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.
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