A Guide To Conservative Care For Heel Pain

Christopher Corwin, DPM

   Physical therapists have many modalities at their disposal. Ultrasound can provide deep heat to the plantar fascia. This can help break up or loosen fibrotic tissue. Some NSAID topical agents are also showing some promise in the treatment of superficial tendon, ligament and plantar fascia pathology when one combines these with ultrasound (phonophoresis). Electrical stimulation is a tool for temporarily reducing pain. Iontophoresis is the transdermal administration of corticosteroids to decrease inflammation by using an electrical charge as the driving force for the medication. Cold packs can control pain and reduce inflammation. One can use cold therapy concurrently with an object (i.e. frozen water bottle, frozen tennis ball, golf ball, etc.) for the dual purpose of inflammation reduction and soft tissue mobilization.

   Physical therapists can also aid in the evaluation of a lower extremity alignment. Limb length discrepancies lead to gait alterations and eventually may cause plantar fasciitis. Some cases of limb length discrepancies are structural in nature and one can treat them with appropriate lifts. A fair number of people are affected by a limb length discrepancy, which has a largely functional component to it. One can also treat discrepancies in the short term with a heel lift on the short side.

   However, this patient will benefit in the long term from skilled physical therapy to address the functional aspect. This may be stemming from a weak core group leading to ilium malrotation and pelvic upslip causing a functional limb length discrepancy. One can correct a pelvic obliquity through muscle energy techniques, manipulations and stretches. Core strengthening and continued home exercises are paramount to long-term treatment success and preventing a relapse.

Pertinent Pearls On Getting Patients To Stretch Correctly

An analysis of the lower extremity must also focus on the posterior muscle groups from the hips (gluteals, piriformis), thighs (hamstrings), calf (gastroc/soleus complex, posterior tibialis) and all the way down to the foot (intrinsics and long flexors).

   Corrections to a lack of flexibility with stretching exercises are very important. Many patients tell you they have been stretching. Make them demonstrate these stretching exercises to you. The importance of proper technique cannot be overstated. Most will be doing something wrong with the stretches and are most often guilty of not holding the stretch long enough. Stretching for four to five seconds is a waste of time. Patients should hold the stretches for 30 seconds. Make sure that these people are not “over-stretching,” not in terms of the number of times per day (which they usually aren’t doing enough) but in terms of the intensity of each stretch. The stretch should increase until patients feel some tension in the tissue. Some patients feel that a “little stretch is good so a big stretch must be better.” This is not the case and may actually prevent the problem from going away.

   Regular stretching must occur throughout the day and not be limited to a couple of minutes in the morning and evening. Stretches should start when the alarm clock goes off in the morning and before the patient gets out of bed even if this means setting the alarm three minutes early. It should become part of the daily routine. Towel or resistance band fascia/gastrocnemius stretches, alphabet stretches and self-massage of the fascia can be very successful in alleviating the post-static pain associated with plantar fasciitis.

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