A Stepwise Approach To Treating Chronic Heel Pain

By Lisa M. Schoene, DPM, ATC

   Given the common incidence of heel pain, patients may present to the office with symptoms that have been present anywhere between two or three weeks to perhaps two or three years. Often, these patients have already consulted with another clinician who had an incorrect approach to treatment. When the pain does not resolve, the patient may feel that he or she has to undergo an unnecessary surgical procedure.    This is unfortunate as the problem may be due to improper care. If the treating clinician does not implement the proper treatment plan, including follow-up and long-term care, the patient’s condition may not resolve. As podiatrists, we must realize that patients come to see us because they have “acute” foot pain. Merely fitting them with a pair of orthotics will not suffice as treatment. We are acute care physicians of the foot and ankle. If we don’t relieve acute foot pain immediately, we are not offering the best of our acute knowledge and care skills that have allowed our profession to maintain its unique role in the medical arena.    Treating patients conservatively but aggressively until symptoms disappear and ensuring the proper progression of care are of utmost importance. This will help facilitate patient satisfaction and perhaps improved revenue as a happy and healthy patient is a good referral source. Accordingly, let us take a closer look at potential etiologies, heel pain symptomatology and the appropriate progression of care for these patients.    In regard to typical causes of heel pain, there may be an underlying biomechanical foot abnormality. Typically, this involves pronatory issues at the subtalar joint or midtarsal joint. In regard to tightness in the gastrocnemius-soleus complex, this may be due to pronated flat feet. Poor shoe choices, incorrect sizes or instability in the shoes can also contribute to heel pain. Increasing activity at home or work or within the exercise regimen are other factors to consider. Increased body weight or carrying heavy loads are other causal factors.    As far as presentation goes, patients typically experience pain when they get up in the morning but the pain may ease up after a short time. They may relate that their pain becomes worse with increased activity at home or work or with athletic activity. Pain typically improves with supportive shoes but becomes worse with less supportive shoes or when patients go barefoot.    Patients with heel pain typically may typically present with occasional calf cramps or soreness/tightness in the gastroc-soleus complex. Presentation may also include lateral column foot pain secondary to compensation via supination of the foot.    In addition to typical presentations, some patients with heel pain may present with atypical presentations such as swelling of foot or the ankle or ecchymosis around the heel. Some may also experience numbness or tingling of the foot or severe burning on the plantar foot. Concomitant low back pain along with sciatica/radicular pain is an atypical presentation. Patients may also experience non-weightbearing pain or pain that wakes them up at night.    If any of these atypical signs and symptoms appear but quickly resolve with the first treatment, they may be related to compensation factors. Keep an eye out for resurfacing symptoms. If these or any other non-traditional symptoms continue and the heel pain does not resolve quickly, reconsider the differential diagnosis.

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