A Guide To Conservative Care For Heel Pain

Christopher Corwin, DPM

   Pay careful attention when patients note what they have tried thus far and how it has worked. How have they modified their activity and has it helped? People may say they have tried and failed at stretching. However, when you ask some follow-up questions, you may find out they attempted two calf stretches for a couple of seconds and gave up. Did the cushioned insoles from the drugstore help for a couple of days or not at all? Detail the prior use of NSAIDs, including dose, frequency and length of use. Careful examination of this area can provide significant clues into what will and what will not help the particular patient.

What To Look For In The Patient Examination

As patients are relaying their history, take a glance and see what shoes they have worn into the office. Are these shoes appropriate for their activity or occupation, or are they broken down and in need of replacement? Have the patient stand up from the exam chair and even take a walk down the hallway. If radiographs are indicated (this is not the place for the debate about taking radiographs on patients with heel pain), then walking to the X-ray area is a great time to watch the patient walk down the hallway. This cursory gait exam can be very informative and happens without patients modifying their gait while thinking about the correct way they should be walking.

   The examination is also very important. Look for biomechanical abnormalities including flatfoot (flexible or rigid), pes cavus, equinus, bunions, hammertoes, limb length discrepancies, etc. Is there pain with side-to-side calcaneal wall compression or just over the plantar fascia and medial calcaneal tubercle? Palpate and percuss for tarsal tunnel or Baxter’s nerve symptoms. Look above the foot and ankle to the alignment of the entire lower extremity. Genu valgum or other knee and hip deformities can lead to abnormal stresses down the kinetic chain.

Emphasizing Appropriate Shoes And Orthotic Therapy Considerations

After establishing that the patient does have plantar fasciitis and not a calcaneal stress fracture, tarsal tunnel syndrome or other pathology, one can formulate a treatment plan. The first step is to remove the causative agent if one has identified it. If the problem is broken down athletic shoes, replace them. If it is a certain exercise at the gym, then modify it. Runners are often able to switch to a bike or do pool running to maintain cardiovascular fitness. If something is tight, stretch it. Failure to address the cause will render most treatment protocols ineffective in the long term.

   Wearing appropriate shoes is the first step in alleviating the pain associated with plantar fasciitis. There are many different types of shoes that patients can wear successfully to reduce plantar fasciitis pain. For men, lace-up style dress shoes tend to work better than loafers. Women should wear small heels. Very flat shoes can be just as uncomfortable, if not more so than high heeled shoes. Both men and women should limit flat shoes and barefoot walking. It is often helpful to wear two or three different types of shoes all in the same day to vary the stress on the feet. When it comes to athletic shoes, ensure appropriate fit to the patient’s activity and foot type. This is where a solid relationship with a technical running store can be very beneficial.

   Depending on the cause of the plantar fasciitis, orthotic therapy may be indicated. One should tailor the device type to the patient. Flexible flat feet would respond well to a rigid orthotic to control the hyperpronation. In contrast, a rigid cavus foot may respond better to a flexible device that does not overcorrect the medial column but incorporates an intrinsic heel cushion to increase shock absorption. The simple addition of a heel lift to the long, pronated limb in a limb length discrepancy may be enough to alleviate symptoms.

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