A Guide To Conservative Treatment For Heel Pain

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 A Primer On The Differential Diagnosis The differential diagnosis for plantar fasciitis is large and varied. The various possibilities include: faulty foot structure, fascial strain or rupture, stress fracture, subcalcaneal bursitis, tarsal tunnel syndrome, nerve entrapment radiculopathy and peripheral nerve compression “double crush,” neuroma, fat pad atrophy, systemic arthritis (such as gout), rheumatoid arthritis and the various seronegative arthridities, tendonitis of the first layer of the plantar musculature or quadratus plantae, infection, plantar fibromatosis or Dupuytren’s contracture and posterior heel pathology.4,8,11-13 Evaluating plantar fasciitis is fairly straightforward most of the time. Patients present with post-static dyskinesia or pain in the heel after rising from prolonged sitting or lying.

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