One of the most common problems I see in my office is the complaint of heel pain. The pain can be described as sharp, radiating, burning, aching, or just simple "pain." Trying the elicit an exact description is so important yet one of the most difficult tasks I have. Each descriptive term can lead me to a different path of treatment, a different diagnosis.
The basic tenet of listening the history of the patient's complaint is the most important part of my job as a Podiatrist, a physician, a healer. Heel pain presents in so many ways, and yet, most patients say they have a heel spur. The classic "Heel Spur Syndrome" describes pain upon awakening in the morning or after prolonged inactivity and then standing and walking. Pain is mostly localized at the plantar central and medial aspect of the heel, near the beginning of the arch of the foot. And then the patient says something about a heel spur with the impression that it needs to be removed surgically.
Most patients have had a friend or family member who've had some sort of heel pain and have diagnosed themselves or have researched the symptoms on the internet, and they have the preconception that the heel spur is the cause of the problem. And if the spur is the cause, then the prevailing thought is that it must be removed.
On the contrary, though, the heel spur, if indeed it is present, is only one of the many symptoms of the underlying problem. The spur is a excessive growth of bone at a site of chronic stress, pressure from pulling or pushing on the anatomical site, or repetitive micro-trauma. The classic spur in the news is the Elbow Spur suffered by many baseball pitchers due to chronic stress on the elbow from the twisting, bending, repetitive motion of throwing various types of pitches that require the elbow the turn and rotate and pull on the ligaments attached to the bones of the arm.
The foot has a major ligament attaching the heel to the bottom of the toes, spanning across the entire bottom of the foot, helping maintain the arch structure of the foot. The mechanism of action of this ligament, called the Plantar Fascia, is an important cog in the biomechanics of the foot during standing, walking, running, or any other movement of the foot. This ligament is constantly under stress, except while at rest. And it is during these rest periods, like sitting for a while or sleeping, that the process of healing the stress reactions to the fibers of the ligament occur. And when the rest is over, the stress on the ligament begins anew, way too soon for complete healing of any micro-trauma caused, hence the feeling of pain in the morning, etc.
It is this repetitive stress that results in the heel spur. The body's attempt to heal itself with increased blood flow to the stressed area leads to low-grade inflammation that is the hallmark of healing. This chronic low-grade inflammation will encourage new bone formation; the body attempts to reduce the stress on the ligament's attachments, essentially trying the shorten the distance the ligament needs to span from the heel to the toes. The larger the heel spur the longer the underlying low-grade inflammation has been present.
So when the heel pain rears its ugly head one morning and the X-Rays show a very large spur, it is only natural to think it is the spur that is the culprit. But this extra bone growth had been brewing for many years, way before the onset of the heel pain.
There are instances of the spur causing the pain, however, especially if the spur is so large that it is touching the nerve that runs along the bottom of the heel. One of the anatomical flaws of the mammalian foot is the Lateral Plantar Nerve which courses under the heel and can get pinched and pressured by excessive bone growth. This pain is significantly different than classic heel pain; the nerve pain can be sharp and radiating and electric in nature and mostly does not subscribe to occurring only in the morning or after rest. It will hurt all the time, worsening with increased activity. Sometimes there is numbness or tingling sensation along the area towards the fourth and fifth digits. The area of the foot that is innervated by the Lateral Plantar Nerve will be most affected.
This is why it is so important to elicit an exact description of the painful symptoms. Although not 100 % diagnostic, the complaint of sharp pain along the inside of the heel and along the arch, worse in the morning with first steps, relieved with walking a bit, is mostly associated with inflammation of the ligament, the Plantar Fascia. Hence the name of the disorder: Plantar Fasciitis.
Heel Spur Syndrome is a generic term used to describe a variety of heel pain, even though the heel spur is not the cause of the problem. If the pain is mostly focused to the bottom of the heel and no radiating pain, discomfort all day with walking or standing, and there is an obvious spur on X-Ray, then the spur can be the root cause. I see this in elderly folk with diminished, atrophied fat pads and a very palpable heel bone. Sometimes a callous builds up under the heels which will add to the problem. The fat pad is the natural fat tissue under the heel that is part of the foot's cushioning structure. This pad disperses, atrophies, and thins over time.
Treatments vary for every type of heel pain. The atrophied fat pad with the prominent Heel Spur will due best with the use of cushions, pads, orthotics, and proper shoe gear. I do not recommend surgical intervention, which is the grinding down of and removal of the excess bone, since this may not resolve the problem. And these patients are usually elderly with a multitude of other systemic problems that increase the morbidity and chance of complications after surgery. The elderly heel bones may also be osteopenic, with less strength, lower bone quality, and higher chance of fracturing.
The classic Plantar Fasciitis treatment should not be treated with surgical intervention until all conservative modalities fail. And even after surgery, there are a multitude of complications that may occur which can be more debilitating than the original heel pain. I have been extremely successful in curing heel pain without the use of surgical intervention. My methods are varied and include a multi-faceted approach to the problem.
My goal is to educate the patient about the cause of the heel pain and the various ways to correct the problem. I start with the shoes and sneakers then review various stretching exercises to reduce to stress on the Plantar Fascia. These include focused stretches on the posterior muscles (Glutes, Hamstrings, Calves, and Plantar muscles of the foot). I review the need for various arch supports, ranging from off-the-shelf devices to custom molded orthotics. I will treat medically with cortisone injections when necessary to reduce the inflammation to the point that the body can naturally battle the chronic pain, and I prescribe anti-inflammatory medications that attack the pain on the systemic level. I am a big believer of life-style changes, ultimately reducing the overall stress with better eating habits, meditation and mindfulness exercises, and general well being. A large percentage of pain anywhere in the body is simply a result of the body's reaction to external stress and it's inability to properly approach it, deal with it, and control it.
Heel pain can be caused by many different things, all resulting in very similar symptoms. It is most likely NOT due to the heel spur.
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