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Heel Pain

By Mark Jenkins, D.O.

Heel pain is a very common musculoskeletal complaint. There are multiple causes of heel pain. Posterior heel pain (the back of the heel) may be caused by retrocalcaneal bursitis, Achilles tendonitis or degeneration, Haglund’s deformity and a pump bump bursa. Plantar heel pain (bottom of the heel) may be caused by a stress fracture, Tarsal Tunnel Syndrome, Lumbar herniated disc, apophysitis and by seronegative spondyloarthropathies (i.e.: Crohn’s Disease, Psoriasis, Reiter’s Syndrome). However, the most common cause of plantar heel pain is Plantar Fasciitis.

The plantar fascia is a thick layer of connective tissue that connects from the inner bottom of the calcaneus (heel) to the toes. It functions as a windlass mechanism to lock out the arch of the foot while walking. The basic pathology of Plantar Fasciitis is microscopic tears of the fascia insertion into the heel. Examination of cells from affected tissue show changes of chronic inflammatory cells instead of healing. Spurs are frequently seen on the X-rays of patients with plantar fasciitis but are rarely the source of pain. Tension on the fascia is also exacerbated by tightness of the Achilles tendon.

The diagnosis of Plantar Fasciitis is based on the clinical exam. X-rays are not necessary to make the diagnosis. When done, MRI’s show fluid and thickening of the fascia at the insertion (inflammation). Most patients are point tender over the medial heel but some are more tender closer to the arch. The pain may worsen by forcing the toes into extension. Tightness of the Achilles tendon is very often found.

The treatment of Plantar Fasciitis is usually non-sugical. Less than ten percent of patients with this diagnosis require surgery. The earlier the treatment is started from the onset of symptoms, the sooner the pain will be resolved. It can take six months to a year for the symptoms to be completely resolved. Initial treatment usually includes a stretching program for the Achilles tendon and the Plantar Fascia, an ice massage, non-steroidal, anti-inflammatory medications (NSAIDS) and cushioning the heel with heel wedges. In especially stubborn cases, physical therapy, steroid injections, orthotics and night splints may be required. Treatment is generally recommended for up to six months before surgery is even considered..

The surgical treatment of Plantar Fasciitis includes sound wave orthotripsy and surgical release of some of the fascia insertion. Orthotripsy does not require an incision. It focuses a radiofrequency sound wave at the fascia insertion. The mechanism of action is to cause localized inflammation that stimulates the growth of new blood vessels to heal the fascia damage and break the cycle of chronic inflammation. The literature on orthotripsy is controversial concerning Plantar Fasciitis. Many studies have combined the results of low and high frequency machines with mixed results. Therefore, some insurance companies will not cover this treatment even though the results of the high intensity machine alone have proven to be quite good. Surgical release of the fascia is accomplished by an open incision or by an arthroscopic release. Either way, the objective of the procedure is to cut some of the fascia to relieve tension on it. The final outcome of both procedures at six months is about equal. Some literature states the patients undergoing the arthroscopic release procedure may recover slightly faster. Complete release of the fascia is controversial. Complete release can cause excessive shortening of the fascia leading to tension on the plantar sensory nerves. This can lead to chronic arch pain.

Dr. Jenkins can be contacted at Chatham Orthopædics, 4425 Paulsen Street, Savannah, Georgia 31405; (912) 355-6615