Conquering Conservative Care For Heel Pain
Heel pain is certainly one of the most ubiquitous complaints among our patients. Plantar heel pain is by far the most common location with proximal plantar fasciitis (heel spur syndrome) accounting for the majority of cases. Proximal plantar fasciitis, otherwise referred to as heel spur syndrome, is common in any podiatric practice and is certainly the most frequently encountered etiology of heel pain. Plantar fasciitis has been reported to comprise up to 10 percent of all foot and ankle injuries. The clinical presentation consists of insidious onset plantar or plantar/medial heel pain. In most cases, patients will note that their pain is worse in the morning and after any periods of nonweightbearing rest. This phenomenon has been referred to as post–static dyskinesia. Quite often, there is an overuse history or increase in weight, although acute onset traumatic causes are not uncommon. Inappropriate shoes with an unstable (excessively flexible) shank may be a contributing factor as well. During the physical examination, patients will have pain upon palpation of the plantar or plantar/medial heel at the junction of the medial band of the plantar fascia and the medial calcaneal tubercle. I will also squeeze the heel side to side and check for pain. If the patient does have discomfort, one must consider the possibility of a calcaneal stress fracture. Ankle equinus is perhaps the most common physical finding and is considered by most to be the most significant etiologic factor. One must rule out other biomechanical factors including cavus foot structure, excessive subtalar/midtarsal joint pronation during gait and limb length inequality. Excessive subtalar joint pronation alone cannot be responsible for plantar fascial strain. Longitudinal midtarsal joint supination with dorsiflexion of the first ray is more of a direct influence upon the plantar fascia. Radiographic findings may demonstrate the presence of a calcaneal spur. This represents a form of enthesiopathy and is usually not responsible for the symptoms. However, in some cases, the plantar heel fat pad has atrophied or displaced, resulting in reduced shock absorption and protection for the calcaneus. In these cases, a heel spur may be the cause of pain and may require horseshoe padding or some other type of orthotic modification to provide more heel cushion. In many cases of heel spur syndrome, the radiographs are completely unremarkable. Offering A Successful Regimen For Conservative Management Conservative management of heel spur syndrome includes Achilles and fascial stretching, physical therapy, an over-the-counter or custom orthosis and injectable or oral antiinflammatory medications. When injecting a corticosteroid, I favor the plantar approach and prefer to deliver the local anesthetic and steroid separately. A low-dye taping is very useful, especially following an injection of corticosteroids. I believe that deep massage is the most essential element when prescribing physical therapy. A plantar fascial night splint may be helpful, especially in more difficult cases. In my experience, greater than 65 percent of patients have an excellent outcome within six months following this regimen. If the patient is not improving within the first few weeks, I frequently will perform a diagnostic test, such as magnetic resonance imaging (MRI), to exclude the possibility of another etiology. How To Maximize Outcomes With Orthotics I usually begin treatment with a prefabricated orthosis, which usually provides an excellent outcome. However, when initial care fails, I will proceed to use a custom functional orthotic device. Current research suggests that forefoot varus posting is not appropriate even in the presence of a forefoot varus or excessive subtalar joint pronation. In one study, wedges placed under the lateral forefoot decreased the strain upon the plantar fascia while wedges placed under the medial forefoot increased fascial strain. Any force that causes first ray dorsiflexion will result in midtarsal longitudinal axis supination and subsequent strain on the plantar fascia. When there is a forefoot varus, you should utilize a first ray cut-out to promote plantarflexion. When there is a forefoot valgus, a reverse Morton’s extension may be useful for maintaining the first ray in a plantarflexed position. Doug Richie, DPM has formulated a “Seal Beach Protocol” for the orthotic management of subcalcaneal pain.