The heel of your foot accepts and transfers an enormous amount of force over a relatively small surface area with each normal step. Now think about how much more force is borne when you are landing from a jump or when running. The tissues in the human heel and foot (the tendons, ligaments, muscle, fascia and bone) are designed for the repetitive stress and strain from normal and even some abnormal activities of daily life, whether wearing a shoe or not. But all it takes is one day where you are more active than usual, are on a hard surface for a prolonged time, or are wearing the wrong shoes for the activity you are involved in, and the result can be heel pain.

If there is an overuse injury to the plantar fascia, which runs along the bottom of the foot from the heel out towards the toes, pain in this area is usually the first symptom a patient will notice. While there can be secondary symptoms such as swelling or bruising, the majority of people presenting with heel pain have just that, pain. In my office, most patients will relate a history of pain on the bottom of the heel when first getting up in the morning. Most patients seem to wait for about a month or longer before making an appointment, and by this time they have seen a pattern of pain after rest, so there is a daily cycle of pain that coincides with their activity level. At this point, most people rate their pain between a 5 to 8 on a scale of 10, and are experiencing pain every day to the point where it is affecting their work or performance in athletic activities.

Since heel pain is such a common complaint, podiatrists have to not only consider the obvious, but also rule out other conditions that can cause the same complaint. This includes a bone fracture or mass in the bone or foot, rheumatology and auto-immune causes, nerve entrapments, and other acute or chronic causes of heel pain. In preteen and teenage boys and girls, heel pain can be caused by an injury to the growth plate in this area, and so it is not an unusual complaint in a young athlete. So the complaint may sound the same from the patient, but the diagnosis can vary, and as a result so are the different treatments. Having said that, the typical patient with heel pain is usually female, age 40 or older, and an above ideal BMI or body mass index. Usually just one heel is painful, but a certain percentage will complain of the same problem in both feet at the same time. An x-ray exam, in addition to a basic physical exam and thorough history, are key to working up a patient presenting with heel pain. The x-ray in a typical plantar fasciitis patient is usually normal, with about half of patients showing a small bone spur near the insertion of the plantar fascia. The finding of a spur in this area, with or with out pain, is considered incidental. Many years ago, it was felt essential to remove or file off this spur in addition to sectioning the plantar fascia when conservative treatments failed, but today we generally cut the inner third to half of the fascia in the more difficult cases.

If the x-ray reveals a fracture in the heel, immobilization and not bearing weight to the painful extremity is most important. This can be achieved with crutches, the use of a wheel chair, or a modified four wheeled scooter designed for this purpose. Plantar fasciitis, however, initially responds well to icing, gentle stretching, oral non steroidal medications such as ibuprofen, and avoiding high impact activities for about a month. An athletic taping to the foot often allows many to continue at or near their activity level. Many patients with pain longer than a month or two also respond very well to a series of injections of a local anesthetic mixed with a steroid. Non-athletes and athletes alike find that an orthotic in their shoe helps to manage the initial pain and decrease the likelihood of recurrence. And finally, your daily choice of shoe gear will play an important part in the course of heel pain, and in the overall general health of your feet. Think soft, wide and accommodative when you suffer from heel pain, and you will not only manage your heel pain, you will likely avoid many other foot and lower extremity problems.

Richard C. Bennett, D.P.M.

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