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Heel Pain, Heel Spurs
The most common form of heel pain, is pain on
the bottom of the heel. It tends to occur for no apparent reason and is
often worse when first placing weight on the foot. Patients often
complain of pain the first thing in the morning or after getting up to
stand after sitting. The pain can be a sharp, searing pain or present
as a tearing feeling in the bottom of the heel. As the condition
progresses there may be a throbbing pain after getting off your feet or
there may be soreness that radiates up the back of the leg. Pain may
also radiate into the arch of the foot. To
understand the cause of the pain one must understand the anatomy of the
foot and some basic mechanics in the function of the foot. A thick
ligament, called the plantar fascia, is attached into the bottom of the
heel and fans out into the ball of the foot, attaching into the base of
the toes. The plantar fascia is made of dense, fibrous connective
tissue that will stretch very little. It acts something like a shock
absorber. As the foot impacts the ground with each step, it flattens
out lengthening the foot. This action pulls on the plantar fascia,
which stretches slightly. When the heel comes off the ground the
tension on the ligament is released. Anything that causes the foot to
flatten excessively will cause the plantar fascia to stretch greater
that it is accustom to doing. One consequence of this is the
development of small tears where the ligament attaches into the heel
bone. When these small tears occur, a very small amount of bleeding
occurs and the tension of the plantar fascia on the heel bone produces
a spur on the bottom of the heel to form. Pain experienced in the
bottom of the heel is not produced by the presence of the spur. The
pain is due to excessive tension of the plantar fascia as it tears from
its attachment into the heel bone. Heel spur formation is secondary to
the excessive pull of the plantar fascia where it attaches to the heel
bone. Many people have heel spurs at the attachment of the plantar
fascia with out having any symptoms or pain. There are some less common
causes of heel pain but they are relatively uncommon. There
are several factors that cause the foot to flatten and excessively
stretching the plantar fascia. The primary factor is the structure of a
joint complex below the ankle joint, called the subtalar joint. The
movement of this joint complex causes the arch of the foot to flatten
and to heighten. Flattening of the arch of the foot is termed pronation
and heightening of the arch is called supination. If there is excessive
pronation of the foot during walking and standing, the plantar fascia
is strained. Over time, this will cause a weakening of the ligament
where it attaches into the heel bone, causing pain. When a person is at
rest and off of their feet, the plantar fascia attempts to mend itself.
Then, with the first few steps the fascia re-tears causing pain.
Generally, after the first few steps the pain diminishes. This is why
the heel pain tends to be worse the first few steps in the morning or
after rest. Another factor that contributes to
the flattening of the arch of the foot is tightness of the calf
muscles. The calf muscle attaches into the foot by the achilles tendon
into the back of the heel. When the calf muscle is tight it limits the
movement of the ankle joint. When ankle joint motion is limited by the
tightness of the calf muscle it forces the subtalar joint to pronate
excessively. Excessive subtalar joint pronation can cause several
different problems to occur in the foot. In this instance, it results
in excessive tension of the plantar fascia. Tightness of the calf
muscles can be a result of several different factors. Exercise, such as
walking or jogging will cause the calf muscle to tighten. Inactivity or
prolonged rest will also cause the calf muscle to tighten. Women who
wear high heels and men who wear western style cowboy boots will, over
time, develop tightness in the calf muscles. Diagnosis The
diagnosis of heel pain and heel spurs is made by a through history of
the course of the condition and by physical exam. Weight bearing x-rays
are useful in determining if a heel spur is present and to rule out
rare causes of heel pain such as a stress fracture of the heel bone,
the presence of bone tumors or evidence of soft tissue damage caused by
certain connective tissue disorders. Treatment Treatment of heel pain generally occurs in stages. At the earliest sign of heel pain, aggressive calf muscle stretching
should be started. Additionally, taking an oral anti-inflammatory
medication and over-the- counter arch supports or heel cushions may be
beneficial. The next phase of treatment might consist of continued calf
muscle stretching exercises,a night splint, cortisone injections and
orthopedic taping of the foot to support the arch. If this treatment
fails, or if there is reoccurrence of the heel pain, then functional foot orthotics
might be considered. A functional orthotic is a device that is
prescribed and fitted by your foot doctor, which fits in normal shoes
like an arch support. Unlike an arch support, however the orthotic
corrects abnormal pronation of the subtalar joint. Thus orthotics
address the cause of the heel pain and abnormal pronation of the foot. Surgery to correct heel pain is
generally only recommended if orthotic treatment has failed. There are
some exceptions to this course of treatment and it is up to you and
your doctor to determine the most appropriate course of treatment.
Following surgical treatment to correct heel pain the patient will
generally have to continue the use of orthotics. The surgery does not
correct the cause of the heel pain. The surgery will eliminate the pain
but the process that caused the pain will continue without the use of
orthotics. If orthotics have been prescribed prior to surgery they
generally do not have to be remade.
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