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Heel Pain
 

Dr. Ian H. Beiser's Podiatry Page

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Dr. Beiser is a podiatrist serving patients in the Washington, DC, area

He is a partner in Foot and Ankle Specialists of the Mid-Atlantic, LLC,  a diverse group of foot and ankle specialists, dedicated to providing advanced and comprehensive foot and ankle care

1145 19th St., NW  Suite #203
Washington, DC 20036
(202) 833-9109

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Plantar Fasciitis

Different Causes of Heel Pain

Plantar Fasciitis

There are many causes of heel pain. However, plantar fasciitis, also known as heel spur syndrome, is the most common, by far. The pain is usually localized to the bottom of the heel towards the inside of the foot. The arch may also be painful.  With this condition, pain is typically most severe with the first few steps after a period of rest. The pain my then subside and then return after extended periods of standing. There is usually no specific traumatic event that is responsible for the condition. It is usually the result of overuse, e.g. too much standing, walking or running. There are several common contributory factors such as weight gain, foot type, shoes. Flat shoes or going barefoot are the worst. Athletic shoes are usually the best. The plantar fascia is a fibrous band or ligament that connects the ball of the foot with the heel and helps to support the arch. When this band gets stretched too much or overused, inflammation results, often at the location where it attaches to the heel bone. A heel spur may develop as a result of chronic pulling by the plantar fascia. However, it should be noted that the pain is not caused by the spur. In fact, in some of the most severe cases, there is no spur at all. In other instances, an X-ray may be taken for an unrelated condition and an extremely large but non-painful spur may be seen. Other causes of heel pain include gout, stress fracture, bone tumors, nerve entrapment and thinning of the fat pad beneath the heel.  Pain at the back of the heel is usually not plantar fasciitis. (Pain at the back of the heel is often due to an inflammation of the Achilles tendon, enlargement of the heel bone or bursitis.)

Treatment for plantar fasciitis should be directed at resting the plantar fascia, providing support for the arch area and limiting pronation.  This is often accomplished with the use of supportive strapping with athletic tape, arch supports and orthotics. Heel lifts may also be helpful. Anti-inflammatories, pills as well as cortisone injections, may be effective as an adjunctive treatment by speeding up the reduction of   inflammation. However, if used alone, anti-inflammatories rarely lead to resolution of the condition. Stretching exercises, physical therapy and night splints may also be helpful. The majority of cases respond to non-surgical treatment although it may take several weeks to reach a comfortable level. In those cases that do not respond adequately to conservative measures, surgical release of the plantar fascia may be considered. However, a new non-surgical treatment called Extracorporeal Shockwave Therapy (ESWT) is now available as an option for recalcitrant plantar fasciitis.

ESWT was approved by the FDA recently for the treatment of chronic heel pain. It has been in use for several years on thousands of patients in Europe and has been successfully used to restore patients with chronic plantar fasciitis to a normal, active lifestyle. ESWT is a non-invasive procedure that uses high intensity sound waves similar to what is routinely used to treat kidney stones. The treatment is usually performed in the office or in an outpatient surgical center. The procedure is performed under local anesthesia and takes about 25 minutes. The shockwaves are directed at the plantar fascia and stimulate an inflammatory healing response.   

               

 

The two photos above show how the foot is placed on the ESWT unit during treatrment and the Dornier Epos Ultra (R) machine by itself.

 

         

These two photos show the Orthospec (R) device. Like the Dornier Epos (R), the Orthospec device treats chronic heel pain by directing acoustic energy (shockwaves) to the plantar fascia.
 

Advantages of  Extracorporeal Shockwave Therapy vs. Surgery

ESWT Surgery
Non-invasive Invasive
In-Office Treatment Usually performed in hospital or surgery center
25 minute treatment session procedure time about 1 hour plus time in recovery room
Usually no pain Pain medication/ narcotics often required after procedure
May return to work the same day Time off work for recovery
No bandages or cast bandages required and casting often required post-operatively

More about heel pain


  Different Causes of Heel Pain

Condition Location Risk factors   Symptoms Treatments Comments
Plantar fasciitis/"Heel Spur syndrome" Bottom of heel, usually towards the inner side of the foot or centrally. Also may extend throughout arch overuse (prolonged standing, walking, running, aerobics, etc.), walking barefoot or wearing non-supportive shoes, weight gain, very high arches or very flexible, flat feet, Pain upon standing after periods of rest is often the most severe (Often followed by some improvement after a few minutes of walking). Pain may then  get worse after longer periods of standing. Taping, arch supports, orthotics, injections, heel lifts, stretching, avoid walking barefoot, wear supportive shoes, rest, ice application, anti-inflammatory medications, night splints, casting,and occasionally surgery By far the most common cause of heel pain. Usually the result of overuse
Tarsal Tunnel syndrome Throughout heel and arch. May extend to toes. Pronating/flat foot, presence of soft tissue mass Burning, numbness, occasional shooting sensations, and pain. Usually gets worse with extended periods of standing  If caused by pronating/flat foot- orthotics often effective. Otherwise, surgery to release pressure on nerve or to remove soft tissue mass  
Bursitis Bottom of heel high arched foot, age, thinning of fat pad below heel pain with weightbearing pressure on heel Orthotics, injections, heel pads  
Haglund's Deformity/"Pump Bump" Back of heel high arched foot, enlarged bump of bone at back of heel pain in back of heel when wearing shoes padding, softer shoes with more room behind heel, injections, surgery  
Gout Bottom of heel history of gout, high uric acid levels sudden onset with possible redness, swelling and pain. Usually resolves within 10 days. anti-inflammatory medication, injection much more common in the big toe rather than the heel
Stress fracture generalized  throughout heel overuse, thinning of fat pad pain whenever standing casting, crutches  
bone tumor generalized throughout heel   varied surgery, casting usually benign
Hyperkeratotic lesion (callus, corn or wart on bottom of heel) localized to area of palpable hard skin   pain when touching or standing on the area of hard skin shaving  

 

 

Ian H. Beiser, D.P.M., F.A.C.F.A.S, F.A.S.P.S.

Foot and Ankle Specialists of the Mid-Atlantic, LLC
1145 19th St., NW  Suite #203
Washington, DC 20036
(202) 833-9109

 
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Copyright 2008 Dr. Ian H. Beiser's Podiatry Page
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