Reconsider Biomechanical Causes In Heel Pain Cases

By David Levine, DPM, CPed

Some days, it seems to be an epidemic. As you read the patient information sheet prior to entering the examination room to meet a patient for the first time, you start to wonder if everyone will eventually wind up with heel pain at some point in their lives. Sometimes it is easy to see why a person might be suffering with heel pain. Obesity, poor shoe selection and a job that requires extensive standing or walking are obvious contributing factors. In other situations, the cause(s) might be more perplexing. For instance, when a patient who has already received orthotic devices or even one who has previously had surgery for plantar fasciitis presents with heel pain, it may be more difficult to pinpoint the cause of the pain. Keeping to a schedule with a waiting room full of patients can make it very difficult to unmask the true etiological factors causing heel pain. Many only consider the simple approach of injecting, administering NSAIDs and stretching prior to recommending surgery. However, delving into the biomechanical issues might lead to even better outcomes and more satisfied patients, and may open your eyes to how other biomechanical conditions may contribute to the problem. What about chronic heel pain patients? These people may have been to their primary care physicians or orthopedic surgeons, received three injections and NSAIDs, and are still enduring pain after three months or more. Indeed, when we are treating this population of patients, we should pay particularly close attention to biomechanical considerations. Key Pointers For Assessing Footwear This starts with the footwear. Look at the type of shoe the patient wears. Simply hold it in your hand and determine whether it meets the following simple criteria. 1. Does the shoe fit? Assessing the insole by looking at the toe print will give you an idea if there is enough room in the shoe for the patient’s foot to spread out and function properly. Also, this may allow you to see if the ball of the foot is located at the proper place. 2. Where is the break point of the shoe? When flexing the shoe, it should bend at the ball of the foot. There are many shoes that flex in the arch. The foot doesn’t bend there so why should the shoe? You want the shoe to work with the foot, not against it. 3. Is the construction of the shoe appropriate for the foot type? For instance, in a foot that has a highly inverted heel strike (i.e. tibial varum), is the upper of the shoe strong enough to remain over the sole? If it isn’t, it will breakdown laterally, forcing the foot to land in an even more inverted position, which will subsequently lead to even more pronation than what the foot would normally do. The opposite can be true as well. With a pronated position to heel strike, the shoe will break down medially and the foot will hang over the sole, leaving inadequate support for the foot and the likelihood of continued strain on the plantar fascia. 4. Is the shoe appropriate? Many people will choose to get shoes by looks or what is on sale. That may work for many people, but once a foot problem develops, the shoe takes on a different meaning. It transforms from something to wear to a medical device. Evaluating the entire person who fits into the shoes will improve your outcome. Even though it may be just the heel that is hurting, looking at the entire person is important. Heel pain may only be a manifestation of more proximal biomechanical imbalances. Going into every iteration of biomechanical possibilities is impossible, but there are some key considerations that warrant a closer look. Top Tips On Evaluating Symmetry One of the most important biomechanical considerations in evaluating patients is symmetry. Simply start with the appearance of the feet. Are they the same? Is there a bunion on one foot or hallux limitus unilaterally? Notice even the subtle differences. If the patient doesn’t have proper balance, something may eventually break down or start hurting. Think of your car. If the front end isn’t aligned, the ride won’t be very smooth. What may appear to be an insignificant difference between the right and left lower extremity can accumulate over time into conditions that force people to seek relief from a variety of medical providers. We live within a medical culture of specialization focusing only on the body part that hurts. That is where we offer a tremendous service. We have the ability to look at the whole person, evaluate how they function and then provide valuable treatment modalities that will address the asymmetry. A good example is in treating individuals who have back pain. There are a variety of pathological conditions that can affect the back, but it may be something simple like a small difference in leg lengths that is the ultimate culprit. Symmetry seems to be especially important in those patients with recalcitrant heel pain. These are the people who have seemingly been through everything from conservative treatments to surgical intervention, get better for a while and then return to your office with either another biomechanical complaint or continued heel pain. In the case of heel pain, it may continue to recur or it may be a situation in which you think you’ve resolved one complaint only to see it resurface in another location. Indeed, it may be the patients with chronic pain are suffering from biomechanical imbalances that keep manifesting themselves in different locations. Why A Thorough Gait Analysis Is So Critical One of the best ways to obtain more clues is through analyzing gait. Watching the patient function will give you additional clues. When evaluating the patient in the examination chair, you have to rely on a static exam and descriptions of function from the patient. You might have them walk in the hallway but you are only getting front and back views. Most often, functional differences and abnormalities are so subtle that you may not pick them up with your own eyes. Another option is to capture the person ambulating on videotape from different angles. This will provide you with an abundance of information that will certainly give you biomechanical ideas on how best to treat your patients that you would never have thought of before. The video gait analysis allows you a few luxuries right off the bat. For starters, you can review it at your convenience rather then when you are rushed in the midst of keeping up with your schedule. In addition, playing it back in slow motion will give you the opportunity to pick up what you missed in the hallway. Taking it to the next level is adding a pressure mapping system. The video lets you see the entire body from different angles. The pressure mapping system lets you see what the foot is doing once it contacts the ground. Pressure distributions, the force with which the foot hits the ground and the pattern of each step will open your eyes even wider regarding foot pathology and how it is intimately linked to the function of everything above the feet. Once you have obtained all of the information, then you can provide biomechanical treatment that makes sense both to you and the patient. The patient will also have a greater understanding of what is wrong and will be more likely to comply with your recommendations. There is a variety of options in treating each patient because each patient is different in his or her activity level, body type and shoes he or she likes and needs to wear. How To Ensure Orthotic Success For Each Individual With chronic heel pain, orthotic devices are often an integral part of the treatment plan. Many articles have been written and opinions have been formed over the years on what type of orthotic is best in treating heel pain. However, we should not look at it from the point of view of what orthotic is best, but rather from the perspective of what the person needs in order to function better. One material choice is not better than the other. It is how the device fits the foot and the shoe. It is also an endless argument on how best to cast each person. The people who do the same surgical procedure on every bunion or cast everyone in the same position are limited in their abilities and understanding of what they need to achieve for their patients. Every foot is different and will behave differently in a supine, prone or semi-weightbearing position. Therefore, understanding what you want to achieve with each patient and each foot should dictate how you cast and what material you select. Some people get fixated on making only one type of orthotic for each and every person and thinking that is the only way it can work. The truth is there is more than one right way to make an orthotic for each person. To prove this, look at the pedorthic profession. Pedorthists have significantly grown in numbers over the last several years and are thriving in the orthoses industry. Despite our differences in training, what they do also works. The main concept is to understand how the foot functions and have a goal of what you are trying to achieve with each particular patient. Even if you take the best cast you are capable of and choose the best material you think is available, the orthotic device will only be as good as the shoe you put it in. Even if you measure carefully for the degrees of posting you want incorporated in the forefoot and are meticulous with the amount of motion in the rearfoot, it will all be for naught if it doesn’t fit the shoe properly or if the shoe is inappropriate. That is why it is crucial to put it all together and make sure it all works like you planned and directed. Helpful Tips On Shoe Modifications Sometimes it is even important to incorporate shoe modifications in your treatment plan when addressing heel pain. A variety of creative shoe modifications can be extremely useful as you address the pathology causing a patient’s heel pain. The modifications range from relasting a shoe to providing a better base of support to add an external lateral or medial counter to hold the foot in place more effectively. Probably the most useful modification in treating individuals with asymmetry leading to heel pain is the lift. When you add the lift to the midsole of just about any shoe, it can provide your patient with a better foundation in which to make an orthotic device work more efficiently. Typically, if your patient needs a 1/8 inch lift, it is easy to slip that in the form of a heel lift inside the shoe. Anything above 1/8 inch needs to be placed externally. There are two reasons why it can not go inside. It will place the foot in equinus and be uncomfortable, and it will cause the heel to slip out and contribute to a poor shoe fit. Placing it discreetly within the midsole is an easy task for a skilled shoe technician. The way to approach this with patients is to suggest doing it on only one shoe and trying it for a two weeks. You will know if it works when they drop off more of their shoes for the same. Final Thoughts Heel pain is a common pathology that we all see and treat on a daily basis. A variety of treatment options, ranging from conservative modalities to surgical options, is available to help our patients get better. It has been proven that conservative treatment is successful in treating anywhere from 70 to 90 percent of patients afflicted with heel pain. With even more scrutiny on biomechanical considerations, you may find you will be closer to 90 percent. It only makes for common sense that the more control you have over the environment in which the foot functions, the better your result will be. Indeed, even in those individuals who go on to require surgery, their pathology occurred for a reason. That reason may only resurface later on as low back, knee, ankle or foot pain, placing you at the helm of providing much needed conservative biomechanical care. Dr. Levine is the Director of Dr. Levine’s Podiatry And Footwear Center in Frederick, Md. Editor’s Note: For a related article, see “Exploring Lesser Known Etiologies Of Heel Pain” in the November 2001 issue of Podiatry Today.

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