A Guide To Conservative Care For Heel Pain

By Eric M. Feit, DPM and Alona Kashanian, DPM

Over the years, podiatrists have become the primary health care providers for all forefoot conditions and most rearfoot conditions. With greater public awareness and increased referrals from primary care doctors, heel pain pathology is perhaps the most common foot pathology we treat in our offices. As a result, many new devices and surgical techniques have emerged in recent years to help improve our outcomes.

Unfortunately, some of these newer methods and techniques are not always necessary and may not demonstrate the same outcomes that some of the research states.

It is critical to listen to lectures and read articles about new methods of conservative and surgical management with respect to heel pain. However, be aware that many of the speakers or authors who are presenting the research are often affiliated with the companies they are speaking about.

When a patient complains of heel pain, it is important to explain to him or her that there is no one magic modality that will resolve the heel pain. It will require a combination of different types of treatment and changes in habits to help resolve the patient’s pain. We always find it interesting when some doctors say that 30 to 40 percent of their patients with heel pain may require surgical care. In our experience, patients who have heel pain syndrome with fasciitis can usually resolve their symptoms in more than 90 percent of cases with conservative management.

Accordingly, let us take a closer look at the realities of conservative care for heel pain and provide a stepwise treatment plan to help improve your outcomes.

Assessing The Possible Etiologies Of Heel Pain
Most heel pain is biomechanical in nature and may develop with increased weight, trauma or overuse with poor shoe gear. The most challenging type of heel pain occurs when there is associated nerve pain either from tarsal tunnel syndrome or medial or infracalcaneal neuritis. Another type of heel pain that may come and go is systemic-related pain (i.e. rheumatoid arthritis, seronegative arthritis or fibromyalgia). When a patient has arthritis-related heel pain, our treatment plan would only include conservative management.

Until there are randomized, double-blind studies demonstrating the safety of extracorporeal shockwave therapy (ESWT), Topaz (Arthrocare) or cryosurgery in these patients, podiatrists should be very cautious. Surgeons rarely perform open or endoscopic methods of surgery on these patients as these procedures may aggravate the patients’ symptoms.

Current Insights On Heel Pain Pathology
Most specialists now believe that plantar heel pain syndrome is caused by acute and chronic inflammation of the fascia. This is beginning to influence our treatment plan in that some patients with acute inflammation, vascular congestion or a possible stress fracture may require Cam Walker immobilization for two to four weeks prior to beginning the early steps in our treatment protocol.

If inflammation is the etiologic factor, then clinical signs such as pain, heat, redness, swelling and histologic evidence of leukocyte accumulation should be present in the acutely inflamed patient.1 In some patients with acute, severe heel pain, there may be a stress fracture, vascular congestion or periostitis of the calcaneus. There have been several studies over the years describing this possibility but it is difficult to determine for certain even with the benefits of nuclear imaging, an MRI or CT scan. The majority of patients will have chronic “fasciitis” and histologically, there may be an increased infiltration of macrophages, lymphocytes, plasma cells, tissue destruction and evidence of repair. However, many chronic patients with heel pain syndrome seem to have a degenerative process without true inflammation of the fascia. Lemont documented this in a study in 2003.1

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