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.

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