Heel Pain
Description
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 than 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 causes 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 without 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. 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 classical heel pain tends to be worse the first few steps in the morning or after rest. Another cause of heel pain is compression of the calcaneal nerve and may be diagnosed thru neuro sensory motor testing.
One other 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, rehabilitation exercises using ultrasound, e-stim, and other physical medicine modalities, cortisone injections and orthopedic taping of the foot to support the arch. If these treatments fail, or if there is recurrence of the heel pain, then 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 - abnormal pronation of the foot.
 Dr. Parker is excited to also offer a new treatment, Extracorporeal Shock Wave Therapy, for chronic plantar Plantar Fasciitis "heel pain". Extracorporeal" means "outside the body". Shock waves are created by very strong acoustic (sound) energy. Your treatment will be performed with a device called the Dornier Epos Ultra. The Dornier Epos Ultra is a shock wave generator very similar to the shock wave devices used to treat kidney stones without surgery. The shock waves are created by a spark plus that is enclosed in a soft plastic dome filled with water. During ESW treatment, this dome is placed close against the heel so that the shock waves pass through the dome to the heel. ESWT has recently been found to be effective for treating chronic proximal plantar Plantar Fasciitis. Surgery to correct heel pain is generally only recommended if orthotics or the Dornier Epos Ultra treatment have not been successful.
 Two new surgical procedures for the treatment of heel pain are now available from Dr. Parker. One uses an endoscope which is a small camera instrument which that allows the surgeon to see "anatomy" inside the body. By using a very small incision, less than ½ inch, this new procedure releases the extreme tension on the plantar fascia which is the cause of the pain in the majority of cases. All of this is viewed on the television monitor by the surgeon.
The second, a more recent development, is now available called the .
Minimally Invasive Means Faster Recovery
With the introduction of the Kobygard system, Dr. Parker can now use one small incision to perform plantar fasciotomy in a matter of minutes. This new technique performed by inserting the Kobygard device through the incision after preparatory instruments have created channels above and below the ligament or fascia. Once the desired section of ligament or fascia has been "released" one or two small stitches are required to close the incision. The procedure itself usually takes less than 10 minutes using a local anesthetic. A sterile dressing is worn for approximately 3 days and then the patient is usually ambulatory in a protective aircast type boot for a few weeks and generally allowed to return to regular shoe wear in four to six weeks. Minimal loss of work is incurred.
Can be Performed in a Minor OR Setting
There are some exceptions to this course of treatment and it is up to you and Dr. Parker 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 illuminate 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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Foot Pain
New Treatment - Radio Frequency (RF) Therapy for Heel Pain
Pain can manifest itself in several areas within the foot, particularly at the heel and near the toes. These occurrences can be the result of injury, as well as changes in the anatomy and or patient lifestyle. Pain in the heel has been the most common complaint; however many patients report pain near the toes, often due to compression and irritation of the nerves.
How do I know if I have Nerve Related Foot Pain?
The foot is susceptible to multiple injuries and inflammatory conditions that can be treated via Radio Frequency Therapy. Moreover, patients who have been treated previously with physical therapy or orthotics may continue to experience pain. Patients who feel a sensation such as burning, tingling, or numbness may be affected by peripheral nerve entrapment, either in the heel or at the toes. Entrapment occurs when inflamed and swollen ligaments, tendons, and muscles constrict the narrow areas in which nerves pass.
However, some patients may not experience the above-mentioned symptoms, instead, they may have pain radiating along the foot upon waking in the morning or upon standing up after an extended period seated; this pain my be temporary or remain present throughout the day.
 What is Radio Frequency (RF) Therapy?
RF Therapy uses radiofrequency energy to disrupt nerve function. The RF energy causes heat to be generated in a very precise area. When this is done to a peripheral nerve, such as those found in the foot, the nerve can no longer transmit pain from the site.
What happens during RF Therapy?
The procedure is done in your doctor's office. No general anesthetic is used during RF Therapy. However, a local anesthetic may be used to numb your skin. The doctor will then insert a thin needle near the point of pain. The doctor may choose to use ultrasound to guide the placement of the needle.
 The doctor will then check to make sure the needle is at the correct nerve by stimulating the nerve. This may cause muscle twitching and provoke some of your pain. Then the doctor checks to make sure no motor nerves are inside the treatment area. Some patients may notice a tapping sensation.
Once the needle has been properly placed, the area will be numbed with more local anesthetic placed deeper within your foot. You may experience some stinging sensation during the injection. The doctor will allow a few moments for the anesthetic to begin working. Radiofrequency energy will then be applied to the problem nerve pathways. This is often performed at more than one location to ensure the pain has been completely alleviated. Each application, or (burn), of the nerves take 90 seconds and is done at a temperature of 80 or 90 degrees Celsius. Your doctor will determine which is appropriate for you based on the location of your pain.
What can I do before RF Therapy?
There is nothing special you need to do before your procedure. Your physician may request that you apply ice packs a day or two before treatment to reduce inflammation in the area to be treated. Your physician will advise you if any such actions are necessary.
What happens after RF Therapy?
You will be monitored after the RF Therapy. When you are ready to leave, you will be given discharge instructions. Since only the area has been numbed, you should be able to walk out of the clinic on your own. Take it easy for the rest of the day.
You may also be given a pain diary. It is important to fill this out because it helps your doctor know how the RF Therapy is working.
You may feel sore for one to four days. This is normal and is due in large part the needle inserted into your foot. Your foot may feel weak, numb or itchy for a couple of weeks. The full pain relief from the procedure usually comes in four to six weeks.
If you received RF Therapy for inter-digital neuritis (pain at the toes), then the toes that have been painful before the procedure may be numb post-therapy. This numbness may or may not be permanent.
How long can I expect pain relief?
Nerves can regenerate after RF Therapy, but how long this takes varies. Your pain may or may not return when the nerves regenerate. If it does, another RF Therapy can be done.
Reference:
- Ayub, A.; Yale, S.H.; Bibbo, C. (2005). Common Foot Disorders. Clinical Medicine & Research, 3(2): 116-119.
- Tallia, A.F.; Cardone, D.A. (2003). Diagnostic and Therapeutic Injection of the Ankle and Foot. American Family Physician, 68(7):1356-1362
- Aldridge, T. (2004). Diagnosing Heel Pain in Adults. American Family Physician, 70(2):332-338
- NIH (2007). Peripheral Neuropathy Fact Sheet. National Institute of Neurological Disorders and Stroke. Last updated February 26, 2007. Retrieved March 19, 2007
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