Charles Morley, M.D.
“It feels like I’m stepping on a hot nail in my heel when I get out of bed in the morning.”
“Once I get going, I don’t sit down even for lunch. I dread the drive home because I know that my heel is going to kill me when I get out of the car.”
Sound familiar? These common complaints make the diagnosis of Sub-calcaneal heel pain syndrome (Better known as Plantar fasciitis or Heel spur) easy. It’s the treatment that can be challenging.
Some of my unhappiest patients describe the classic plantar heel pain (like a stone bruise) that is worse after rest (overnight or sitting for lunch). Their frustration results from the frequent failure of conservative treatment.
The literature is filled with suggestions for relief ranging from acupuncture to magnetism to pads to splints to exercise to huge spring-loaded shoes to various injections to surgery (scope vs. open release vs. sonic boom). Whew. Worse, the victim inevitably knows someone who was miraculously cured by one of the above modalities administered by another doctor in another state.
Despite the millions of words written about the problem, not much is clear. A thick band of plantar fascia arises from the bottom of the heel as an extension of the Achilles tendon and fans out across the arch to insert all over the place in the distal forefoot: the toe bones, the flexor tendon sheaths, even the skin (much like the palmar fascia in the hand). The consensus holds that degenerative tears develop at the origin and cannot heal because of the relentless trauma of everyday activity. The inflamed tissue swells when pressure is relieved (at night or while sitting), causing increased “first step” pain on arising. After a few steps, the edema is relieved by the intermittent massaging of weight bearing. A false sense of improvement ensues…for a time.
Distilling numerous articles, lectures, and 30 years of experience listening to patients, I have evolved a staged approach to plantar heel pain.
But first, the caveat: not all heel pain is plantar fasciitis. Don’t miss the rare stress fracture (start-up pain not dramatic, usually hurts worse as the day progresses) or the even rarer tumor (hurts around the clock, even at night). Don’t forget collagen disease.
Next, the addendum: for reasons unclear to me, tarsal tunnel syndrome (burning forefoot numbness that lasts 30 minutes or more at the end of the day—afterburn) occasionally accompanies heel pain. Check for a Tinel’s sign, especially over the medial heel pad.
Now, the treatment.
Stage One. Gel heel pad plus the all important stretching program. Period. That’s it. The key is the stretching.
Ignore the rolling eyes of the patient who was hoping for a miracle shot or at least an expensive orthotic. Emphasize the crucial need for the stretching to be done at least three times a day for three minutes for three months. More is better; less is ineffective. The patient sits with the affected leg crossed in a Figure 4 position, then reaches down with the ipsilateral hand to pull the toes into maximum dorsiflexion, thereby tightening and stretching the plantar fascia. Hold for 30 seconds by the clock. Repeat six times per side. Throw in some calf stretches. Eliminate high impact exercise, especially treadmill.
Expect 80% of patients to be well in 3-4 months.
Stage Two (for the 20% who continue to have pain). Apply a short leg walking cast for six weeks. A CAM walking boot is a much less effective compromise. Expect 85% of the patients to experience relief. Follow cast removal with 3 months of Stage One stretching.
Stage Three (for the 5% who are still hurting). Surgery, especially for those with an associated tarsal tunnel syndrome, may be indicated. Reviewing our SportsMed experience, the Foot and Ankle Division operates on less than 2% of our heel pain patients.
In conclusion, NSAID’s, occasional steroid injections, P.T., and orthotics: all have their advocates. What works for some definitely does not work for all when it comes to heel pain.
Primum non nocere.