A Guide To Conservative Treatment For Heel Pain

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Continuing Education Course #114—November 2003

I am very pleased to introduce the latest article, “A Guide To Conservative Treatment For Heel Pain,” in our CE series. This series, brought to you by HMP Communications, consists of regular CE activities that qualify for one continuing education contact hour (.1 CEU). Readers will not be required to pay a processing fee for this course.

Plantar fasciitis is a common condition with many possible causes. In this article, Dr. John Mozena not only describes the principles of conservative treatment, but also provides an insightful, step-by-step treatment paradigm. He also offers tips on stretching and footwear that you can pass on to patients.

At the end of this article, you’ll find a nine-question exam. Please mark your responses on the postage-paid postcard and return it to HMP Communications. This course will be posted on Podiatry Today’s Web site (www.podiatrytoday.com) roughly one month after the publication date. I hope this CE series contributes to your clinical skills.

Sincerely,

Jeff A. Hall
Editor-In-Chief
Podiatry Today

INSTRUCTIONS: Physicians may receive one continuing education contact hour (.1 CEU) by reading the article on pg. 69 and successfully answering the questions on pg. 74. Use the postage-paid card provided to submit your answers or log on to www.podiatrytoday.com and respond electronically.
ACCREDITATION: HMP Communications, LLC is approved by the Council on Podiatric Medical Education as a sponsor of continuing education in podiatric medicine.
DESIGNATION: This activity is approved for 1 continuing education contact hour or .1 CEU.
DISCLOSURE POLICY: All faculty participating in Continuing Education programs sponsored by HMP Communications, LLC are expected to disclose to the audience any real or apparent conflicts of interest related to the content of their presentation.
DISCLOSURE STATEMENTS: Dr. Mozena has disclosed that he has no significant financial relationship with any organization that could be perceived as a real or apparent conflict of interest in the context of the subject of his presentation.
GRADING: Answers to the CE exam will be graded by HMP Communications, LLC. Within 60 days, you will be advised that you have passed or failed the exam. A score of 70 percent or above will comprise a passing grade. A certificate will be awarded to participants who successfully complete the exam.
TARGET AUDIENCE: Podiatrists.
RELEASE DATE: November 2003.
EXPIRATION DATE: November 30, 2004.
LEARNING OBJECTIVES: At the conclusion of this activity, participants should be able to:
• identify factors that contribute to plantar fasciitis;
• discuss what different diagnostic tests can tell you about the condition;
• explain the principles of initial treatment and physical therapies;
• recommend supportive footwear and exercises to your patients; and
• explain the role of patient compliance and activity modification as it relates to resolving plantar fasciitis.

Sponsored by HMP Communications, LLC.

The author recommends using a night splint when patients still have pain greater than three (on a pain scale of one to 10) two months after treatment.
Long-distance runners commonly present with heel pain and they will usually report a recent change in their training routine such as a rapid increase in mileage or running up steep hills.
During a patient’s initial visit for heel pain, the author applies taping (as shown above) in addition to emphasizing activity alteration and proper shoe gear.
74
Author(s): 
By John Mozena, DPM

Plantar fasciitis is certainly one of the most common conditions we see in podiatric practice and more than 90 percent of patients are cured with conservative treatment.1 It sounds relatively simple. Well, in order to consistently facilitate successful outcomes, not only must one have a strong anatomical understanding of the plantar fascia, there must also be a strong command of the various causes of the condition, key diagnostic indicators and when to apply various treatment solutions in the armamentarium.
The current thinking is that plantar fasciitis is a chronic degenerative/reparative process secondary to stress overload with an insidious onset of weeks to months.2 Histologic studies confirm this etiology, with findings of fascia microtears, collagen necrosis, chondroid metaplasia and angiofibroblastic hyperplasia. This could explain why the syndrome is found in both overweight and active individuals.2
Overuse and over-training can contribute to the cause of plantar fasciitis.3,4 Any motion of the foot that puts excessive pull on the plantar fascia at the calcaneus will be a factor in the development of plantar fasciitis.5 Inflammation of the plantar fascia is more often seen in females and people of middle age.6 Contracture of the intrinsics, especially the flexor digitorum brevis, can be a predisposing factor for this condition.6

Often, you will find that those with plantar fasciitis have a history of exercising or working on hard, unyielding surfaces or are on their feet for prolonged periods of time.3,7 Improper conditioning can also be a factor as tight Achilles/hamstring tendons or ankle equinus may cause excessive pull on the plantar fascia.3 Improper shoes that bend in the wrong place, are too wide, have soft heel counters and/or do not have enough support can cause plantar fasciitis.3 Excessive shoe wear is also a common culprit in causing this condition.3
There are two typical kinds of patients that present with heel pain syndrome. You may see a fair number of middle-aged, overweight patients who work in jobs that require prolonged standing on hard unyielding surfaces.8 You will also see long-distance runners presenting with heel pain and they will usually report a recent change in their training routine, such as a rapid increase in mileage, running up steep hills, using athletic shoes from last season or using the shoes for longer than six months or 400 miles.9,10
The condition can have structural causes as well. Having a pes planus or pes cavus foot can be the root cause of heel pain.11 Indeed, the following foot types are associated with plantar fasciitis: uncompensated rearfoot varus, partially compensated rearfoot varus, partially compensated forefoot varus, compensated forefoot varus, forefoot supinatus, flexible forefoot valgus, rigid forefoot valgus, compensated congenital gastrocnemius equines or compensated transverse plane deformity.11 Limb length discrepancy may also cause plantar fasciitis in the long limb.12

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