When
pain and tenderness occurs in the bottom of the heel, most commonly the
problem is related to an inflammation of the Plantar Fascia. This
discussion will focus on pain on the bottom of the heel and not to pain
involving the
ankle joint or the rear of the heel.
Besides plantar fasciitis, there are a few
other conditions that need to be considered in diagnosing heel pain. These
conditions include ruling out the presence of a calcaneal stress fracture,
an entrapment of the nerve going to the inside or outside of the heel,
radiating pain from sciatica from the hip or back and / or an nerve
compression in the ankle called tarsal tunnel syndrome. In
teenagers, there is also a common condition with the growth plate causing
bottom of the heel pain called Sever's Disease.
PLANTAR FASCIITIS AND
HEEL SPUR SYNDROME The Plantar
Fascia is a strong inelastic band of fibers which begins at the heel and
extend into the toes. When the Plantar Fascia becomes inflamed, the
pain is mainly in the arch of the foot. Medically, this condition is
called Plantar Fasciitis. When the Plantar fascia becomes inflamed
and the pain is mainly in the heel, medically this condition is called
Heel Spur Syndrome. The usual cause of Plantar Fasciitis or Heel
Spur Syndrome is excessive pulling on the Plantar Fascia from either
excessive exercise, poor fitting shoe gear or poor foot alignment while
running or standing.
Plantar fascia pain usually begins as a
mild pain to either the arch area or the bottom of the heel. The
discomfort in the foot is usually most noticeable with the first step in
the morning and seems to improve after a period of "warming up" the foot.
If untreated, the pain can become intolerable. In some
individuals, actual heel spur formation can occur at the site of where the
Plantar Fascia is connected to the heel. The heel spur is actually a
ridge of bone which forms to reinforce where the Plantar Fascia attaches
to the heel. The ridge of bone is not the main problem unless a
small nerve under the Plantar fascia becomes entrapped. The Plantar
Fascia is the primary pathological anatomical structure that is causing
pain to the patient. If the pulling on the plantar fascia is
corrected, it is important to understand that the heel spur that formed
from the pulling is not important and does not need to be removed with
surgery. There are many doctors who get the heel spur confused and
tell the patient that a heel spur is causing their pain when in fact it is
the injury to the Plantar Fascia that needs to be medically
treated.
Home care for either Plantar Fasciitis or
Heel Spur Syndrome primarily consists of resting the foot, applying ice to
the affected area three times a day for ten minutes, and using a
supportive athletic shoe for most activities during the day.
Sometimes stretching the arch by rolling the foot on an empty soft
drink bottle in the morning helps relieve some of the pain. In
addition, using a heel pad or a padded insole can be helpful in relieving
the pain in the heel. If these home treatments do not relieve the
pain, treatment by a foot and ankle specialist is
warranted.
In treating heel and arch related foot
pain, an X-ray of the foot is usually obtained to rule out a rare heel
stress fracture and to document if a heel spur has occurred. Sonography
is used to evaluate the plantar fascia for signs of inflammation or
tears. Once a
diagnosis is made of either Heel Spur Syndrome or Plantar Fasciitis,
initial treatment usually consists of orthopedic strapping, anti-inflammatory medications, the
use of a night splint and functional foot orthotics. A night splint
is required to hold the foot in the correct position during sleep to allow
the Plantar Fascia to heal in the correct length as when standing and
walking. A functional orthotic is required to control the amount of
pulling that is occurring in the Plantar Fascia with weight bearing by
controlling the position of the foot in the shoe. In some cases a
cortisone injection is placed into the area of the origin of the Plantar Fascia
to rapidly reduce the amount of pain that is present.
Surgical intervention for
either Heel Spur
Syndrome or Plantar Fasciitis is rarely indicated and should be considered
only if a night splint and / or the functional foot orthotic
has failed. The surgery is warranted if the Plantar Fascia band has
become too short due to repeated injury to where the Plantar Fascia or the
nerve under the Plantar Fascia has become entrapped. The surgery
should only be performed by an experienced surgeon. The primary
purpose of the operation is to lengthen the Plantar Fascia where it is anchored to the heel
bone.
Because Heel Spur Syndrome and Plantar
Fasciitis is an inflammatory condition, early intervention is essential to
stop the repeated scarring of the Plantar Fascia that can lead to
irreversible shortening of the Plantar Fascia, nerve entrapment and the
formation of a painful adventitious bursa.
SEVER'S DISEASE OR
CALCANEAL APOPHYSITIS
Sever's Disease is a common condition in
early teenagers due to the blood supply to the growing plate is not
keeping up with the demands of growing. The pain that occurs is a
deep ache or soreness to the corner of the heel and tends to be aggravated
with running activities. The pain can be debilitating for a
youth. Treatment consists of ultrasound to the heels with message
therapy two to three times a week for two to three weeks, decreasing
athletic activities for two weeks and the use of custom made foot
orthotics to help improve foot biomechanics. Prior to treatment,
x-rays and sonographic evaluation should be obtained to rule out any problem with the growth plates
in the foot and ankle.
CALCANEAL STRESS
FRACTURE
Calcaneal stress fractures would present
with a sharp pain to the heel that would increase with weight bearing but
would not be any more painful with the first step in the morning such as
is seen with plantar fascitis. X-rays are the standard test that is
performed but a CT may be indicated do to the square shape of the
calcaneus. Treatment is non-weight bearing in a cast for at least 6
to 8 week depending on the severity of the stress fracture. Early
treatment is essential to prevent a further fracture of the calcaneus.
CALCANEAL NERVE
ENTRAPMENT
There is a nerve called the Medial
Recurrent Calcaneal Nerve off the Posterior Tibial Nerve from the ankle
that goes under the inside of the heel. This nerve can become
entrapped and cause a burning pain to the underside of the heel. The
pain can mimic plantar fascitis but does not increase with the first step
in the morning. The symptoms for this nerve entrapment would include
a burning type pain, tends to be worse at night and has a point of maximal
tenderness where the nerve is entrapped. Diagnosis is made by
numbing the point of maximal tenderness and determining if the pain
disappears while the local anesthetic is working. Treatment would
include removing whatever is pressurizing the nerve such as changing
shoes, trying the use of a pad over the area to reduce the pressure on the
nerve, cortisone injections to calm down the inflamed nerve and /or
surgical decompression if necessary. There is also a rare entrapment
of the nerve to the under side of the heel from the outside of the foot.
This nerve is called the Lateral Recurrent Calcaneal Nerve from the
Sural Nerve in that the pain would radiate toward the outside of the
foot. Entrapment of the Lateral Recurrent Calcaneal Nerve is
associated with a large calcaneal spur at the beginning of the Plantar
Fascia on the heel bone.
TARSAL TUNNEL
SYNDROME
Tarsal Tunnel Syndrome is a rare condition
in the ankle that is commonly misdiagnosed because the symptoms can mimic
different conditions in the foot. The nerve that is being compressed
in the tarsal tunnel innervates the entire bottom of the foot and all of
the muscles in the bottom of the foot. Because the Posterior Tibial
Nerve is such an important nerve and because it innervates most of the
foot, when the nerve becomes injured from excessive pressure in the tarsal
tunnel, the nerve can give off many different types of pains. The
key to making the correct diagnosis is obtaining a good history of the
patient and having the experience to suspect the that the tarsal tunnel is
the problem to the patient's pain. Tarsal tunnel syndrome is usually
associated with a radiation of pain either up or down the leg or
foot. Diagnosis is based on clinical judgment and performing a local
anesthetic block to determine if all of the pain is resolved with numbing
of the tarsal tunnel. Nerve conduction studies are performed but
only are positive after the Posterior Tibial Nerve has lost half of its
function. Diagnosis of Tarsal Tunnel Syndrome should be made prior
to and not after the nerve has lost half of its function. Treatment
for Tarsal Tunnel Syndrome consists of resting the nerve by either using orthotics,
a night splint or casting for a month. In addition, cortisone injection
therapy, anti-inflammatory medicines and physical therapy can all be used
singularly or in combination. Very rarely is surgery needed for this
condition if adequate conservative measures are employed.
