Your Marvelous Heel...!

Your heel is not a simple structure. It is a region comprised of a variety of body tissues. Thickened skin covers a unique network of shock-absorbing fat tissue. Below this is a binding-layer called the plantar fascia, which is attached to the heel bone. From the fascia and the heel bone arise the origins of several important muscles of your foot. Your heel bone itself is covered by a special regenerative tissue layer; that periosteum helps feed and repair the body of the bone. Among these tissues tissue layers are blood vessels and nerves. Your heel bone itself is composed of an arched array of bony struts and a thin, hard bony shell. The heel bone has several joint surfaces which work with the "talus" (ankle bone) and two other rearfoot bones. All of this is supposed to be arranged in a very specific, normal pattern (anatomy) so that they (and your foot, leg, etc.) function properly (biomechanics).

Is YOUR heel your 'Achilles heel'?

Your heel tissues have their own qualities, strengths and weaknesses. Each of your tissues can be DIRECTLY injured, inflamed or infected, either singly or in combination. Also, your heel can be INDIRECTLY affected by your body's general chemistry, hormones, and immunological system. The heel can be the target of more distant elements and functions of the skeletal system, blood system, nerve system, infections, and circulating toxins. If your foot anatomy is not properly arranged, either at birth or by acquisition, the heel can suffer. If it suffers, you suffer.

Under the microscope (so to speak)

Your podiatric physician (podiatrist, AKA foot doctor) realizes that any or some of the above tissues could be involved in your heel pain dilemma. Your podiatrist also realizes that one or more distant factors could be the origin of your symptoms and suffering.) And, your podiatrist has been trained to recognize abnormal foot and leg arrangements and to recognize their abnormal workings (pathomechanics or dysfunction) which could cause your heel symptoms.

At times, it is necessary to test and examine several of these systems to find the answer to the question: why does my heel hurt. A discussion of how and when the problem began leads to questions about your current and past health history, current medications, allergies, surgical history and other factors. A review of your lifestyle, activities and environment at work, home or play may suggest a situation which allowed the development of your heel problem. Questions may also be raised about influences above the heels, such as involving you knees, hips and back. Medical conditions from which you suffer may also shed some light on the cause of your heel pain. At times, laboratory blood tests may be ordered to rule out (or in) some of these "systemic" conditions. X-rays of your heel and foot are then taken to rule out heel pains arising from such as fractures, bone cysts, infections, foreign body, in your ankle, heel or foot.

A clinical exam provides more information about how your heel is being used by the rest of the body as you stand, walk and perhaps run. Any point of maximum pain is located and considered. The alignment of the foot bones and joints are evaluated. The style and action of your arches, both on and off of your feet, are evaluated. The position of your heel in stance and gait is observed. The foot and leg are checked for excessively tight (contacted) or loose tendons and for spastic, loose or weak muscles. The flexibility or tightness of the tendo Achilles (heel cord) is checked. You are observed as you walk. Even more sophisticated laboratory tests might be employed when a diagnosis is more difficult to reach a diagnosis or treatment approach. Only then can elements of a treatment plan be formulated and offered and pursued.

Sorting it all out...

Professional experience has taught us that the most common cause of heel pains is from mechanical forces. This could be a single blunt blow to the soft tissues under your heel. However, more likely, it is repeated, excessive traumas, repeated micro-traumas to one or more of the heel tissues, especially that of the plantar fascia. This frequently results in inflammation of the fascia and the periosteum. Inflammation and pain of the plantar fascia is called "plantar fasciitis" (yes, there is NO "e" in plantar and yes, there are two "i's" side by side in fasciitis). Both the bone and the fascia can be inflamed, swollen and painful, and may also involve also the tendo Achilles and adjacent muscles and fat tissues. If persistent, these forces can cause the formation of a secondary bony spur under the heel. (Please note: the finding of a "heel spur" upon x-ray is NOT the cause of the pain but rather evidence that your foot has been malfunctioning far longer than your symptoms suggest. Very rarely now does a "heel spur" have to be removed!). It is usually the inflammation that causes the spur, not the other way around!

Down and out with Pronation

Many times, the cause of excessive plantar fascia-to-bone traction will be excess "pronation" (a complex movement within the foot, heel, foot, ankle, leg and thigh and hip). Normal pronation allows your foot to become more mobile so that it adapts to the ground as you walk. There are certain foot and leg arrangements which force the foot to over-pronate. If your foot has one of these undesirable arrangements, you are more likely to overwork the tissues in your heel,foot and leg. Plantar fasciitis is more likely to occur if you have abnormal arches or overworked arches. People with very flat feet infrequently develop plantar fasciitis. Being overweight, fat or obese can increase the load and abuse of your feet and in particular you heel and arch. Shoes can hurt or help your heel and foot in additional ways.

Your Podiatrist to the Rescue

It is your podiatrist's task to examine you and sort this all out, then make recommendations for your care. If symptoms and findings suggest that a medical problem is a significant component of your heel pain syndrome, then you will be referred back to your primary care physician (PCP) or some other specialist (e.g. rheumatologist), while your podiatrist manages the local manifestations.

If mechanical forces are to blame, the treatment focuses on relative rest of the foot and other long-term control of them. Mechanical control can include the use of


relative rest of the painful foot (curtailing excessive activities),

special stretching exercises of the muscles of your foot and legs,

night-time bracing of the leg, ankle, foot,

a change in your work style, duties and environment,

alternative recreational activities (e.g.,swimming instead of jogging),

use of the most appropriate shoes and avoidance of the inappropriate styles,

body weight reduction under MD supervision,

tape strapping of foot with padding of the heel,

trial use of commercial heel pads, cushions, or 'arch supports,'

custom-made, podiatric, functional orthotics (for the best control of your foot function).

Equally important are efforts to reduce your suffering as quickly as possible, while you foot is being helped to heal itself. Such symptomatic relief can include the use of


specific shoe modifications,

specials shoe inserts, lifts or padding,

professional, repeated taping or strapping of the foot,

pain-blocking with ice massage of the heel,

use of OTC pain medicines (e.g. non-aspirin acetaminophen),

podiatrist-guided use of NSAID's (Non-Steroidal, Anti-Inflammatory Drugs) for inflammation and pain reduction,

steroid anesthetic injection (for quick reduction of intensely painful pockets of inflammation and pain),

Anesthetic injection for diagnosis and treatment of local nerve-related heel pain,

manipulation and massage therapy.

Ultrasound and other physical therapies, for deeply warming of injured tissues to improve blood, food, oxygen distribution in them,

What if....

Despite these possible ways of treating heel pain syndrome, the problem may be so significant and resistant that it may take months for good control, healing and reduction of symptoms. If and when it becomes apparent that there is still insufficient relief, then additional testing and consultations may be required. Only, if after many months, the heel is still very much a problem, and IF the you have tried and complied with all other recommendations and options (including weight reduction), then you still have options!

• The SHOCKWAVE Option:
  Using focused sound-wave technology, similar to that used during the non-invasive treatment of painful kidney stones, some podiatric have had some success in reducing chronic, otherwise intractable heel pains with "shockwave" therapy. Though the way it works is not clearly understood, the focused-sound shockwave treatment may include an intentional, controlled irritation of the inside of the heel so as to "jump-start" a stalled healing process. This is usually reserved only when and if conservative treatments have failed. Though usually performed in an ambulatory surgical center, no incision or cutting is performed. Your podiatric physician can provide more details.
• The Surgical Approach:
  Again under certain limited circumstances, it may be appropriate to consider surgical intervention. Only about 1 person in 50 with persistent heel pain even becomes a candidate for this invasive surgery. This can include elements to free up trapped nerve(s), partial cutting/release of the plantar fascia (from the heel bone), and removal of any associated heel (bone) spur. These are usually considered options of last resort since recuperation can be prolonged and there are no guarantees they they will work perfectly or surgical complications may develop too. At this point, if consideration is considered, getting a second opinion from another podiatric surgeon (no some otherwise well-meaning neighbor or friend) would be appropriate. The American Podiatric Medical Association (APMA) has additional information about heel pain syndrome too: www.APMA.org/heelpain

Give us a Call

As we have suggested, a significant heel pain problem is not necessarily simple to figure out and sometimes not easy to treat and overcome either. However, we are up to the task and will welcome you (and your painful heel). If you are suffering and would like to get on with the activities of your life, give us a call.

We look forward to serving you, your family and friends for this and other toe, foot, heel and ankle concerns.

Dr.Ken Sokolowski