By Robert C. Olson, D.P.M.
Heel pain is the most common new patient complaint seen in the typical foot and ankle practice. Many people refer to heel spurs as their problem. Although patients may have a spur, the vast majority don’t cause the patient pain. This small projection of bone is caused by traction of the plantar fascia, which attaches to the site of the spur on the calcaneus or heel bone. Plantar fasciitis or inflammation of the plantar fascia is the most common cause of heel pain.
The plantar fascia is a thick band of tissue that runs from the ball of the foot to the heel. While standing, it is taut like a bowstring adding support to the arch. This condition is often an overuse type of injury, however in many patients, the cause or inciting injury may not be known. Typically patients suffering from plantar fasciitis complain of pain when arising from bed or a seated position. This generally decreases with walking. As symptoms progress pain may begin to recur or worsen with activity throughout the day. In most patients this affects one foot, but it can affect both feet simultaneously.
This diagnosis is made clinically based on patient history and clinical exam. X-rays are taken to rule out a bony problem such as a cyst or stress fracture of the calcaneus. In more difficult or recurrent cases ultrasound, magnetic resonance imaging (MRI) or other testing modalities may be necessary.
Conservative treatment is successful in relieving symptoms in greater than 90% of patients. Activity modification, icing, stretching, change in shoe gear and over the counter arch supports are often able to resolve symptoms in mild cases. In more severe cases, corticosteroid injections, physical therapy modalities and custom orthotics are beneficial. For patients with recalcitrant symptoms not responding to the above treatments, extracorporeal shockwave therapy (ESWT) is a very good alternative to surgical intervention.
Surgical treatment is required in the 5-10% of patients with heel pain that don’t respond to conservative treatment. There are multiple surgical approaches that may be used. The basic underlying procedure, despite the approach, is to release the plantar fascia from its attachment to the calcaneus. If there is a spur it may or may not be removed. Unless the spur is very large, there typically isn’t any change in outcome. Postoperatively a period of non-weight bearing, followed by gradual progression to full weight bearing is required. It is often recommended that patients use arch supports or custom orthotics after surgery to aid in support of the arch, as the plantar fascia is no longer acting as a supportive structure.
This common problem is very treatable, especially if caught early. Many patients, however, wait to seek treatment until symptoms have been present for several months and are virtually unbearable. This delay may make the recovery process much longer and treatment more difficult.