Heel Pain and You

Causes and Treatment for a Common Foe

What is Heel Pain?• The human foot is

largely a triangle• The plantar fascia is

the base of the triangle• This supports the arch• Can be pulled, strained

and injured with activity

Plantar fascia

What is Heel Pain?• With increased load on the

foot, the fascia is stretched and inflamed

• Once inflamed, every step injures it over and over again

Causes of Heel Pain• Overuse

syndromes– Carrying heavy

loads while walking – Increased body

weight– Overstretching

activities

Causes of Heel Pain

• Trauma– Fall from a height

• Frank fracture

– Constant and repetitive load on the feet• Stress fracture

– Weight falling on the foot

Causes of Heel Pain

• Infection– Direct extension

• Stepping on sharp object

– Hematologic spread• Distal infection travels

through the blood

Causes of Heel Pain• Biomechanics

– Flatfoot condition– Tight Achilles tendons– Bunion deformities– Painful areas causing

alteration of gait– Inappropriate shoes

Causes of Heel Pain• Arthritides

– Rheumatoid arthritis – Ankylosing spondylitis (Marie-Strumpel)– Gout– Psoriatic arthritis– Systemic lupus erythematosis– Reiter’s syndrome– Enteropathic arthritides (Irritable bowel syndrome)

Causes of Heel Pain• Entrapment of nerves in the spine

(radiculopathy)• Lesion at the DRG (dorsal root ganglion)• Lesion at the peripheral nerve or terminal branch• Test by NCS (nerve conduction studies), EMG

(electromyographic studies), F wave and H reflex studies or magnetic resonance imaging

Causes of Heel Pain• Tumors of bone are a

rare but serious cause of heel pain

• Pain in the heel or fracture through the tumor may be the first sign

Treatment of Heel Pain

• Non-steroidal anti-inflammatory medications• Steroidal anti-inflammatory injections• Orthotics• Proper shoes• Stretching exercises (?)• Physical therapy

Treatment of Heel Pain (when conservative measures fail)

• ESWT • Surgery• Tarsal tunnel

release

Tarsal Tunnel Release• Entrapment of the

Posterior tibialis nerve with medial calcaneal branch to the heel

• Release is like a carpal tunnel procedure, but for the ankle

Achilles Tendinosis Pain• Due to strain of the Achilles

tendon– Possibly short Achilles

• If chronic, may cause a bone spur (Haglund’s deformity)– Never inject steroids near this– Except for heel lifts and open-back

shoes, very little conservative treatment for this

– Surgical correction of the bump and the short Achilles is best

Heel Pain (conclusions)• If you work on your feet, wearing decent shoes can help avoid

significant problems.• Once the pain presents itself, 99% of Plantar fasciitis problems

can be dealt with via conservative means (Non-steroidal anti- inflammatory therapy and Steroidal anti-inflammatory injections) and orthotic support in the shoes

• If conservative measures fail, ruling out a spinal entrapment, Tarsal tunnel syndrome or arthritides must be done before any consideration of ESWT or surgery

Thank You