A Guide To Conservative Care For Heel Pain

Start Page: 42
Christopher Corwin, DPM

   There is an opportunity to stretch every time the patient gets up from an extended period of time being seated, gets out of a car or comes back to the office chair. The bars on the bottom of a desk chair attached to wheels function well as built-in stretching devices that are routinely accessible during the day. Patients who spend a considerable time at their desk should also make sure that the chair is set up for them appropriately. Poor ergonomics are often a hidden underlying cause of recalcitrant heel pain and can delay healing if they go unaddressed.

Evaluating Joint Mobility And Soft Tissue Dysfunction

In addition to assessing the posterior muscle group, evaluate joint mobility. Look for talocrural joint restrictions that may limit dorsiflexion of the foot. Is the midfoot hypermobile or restricted? Is the distal fibula anteriorly displaced, limiting foot dorsiflexion from a previous ankle injury? If this is the case, this patient would benefit from mobilization of the restricted joints to restore the anatomical alignment and mobility of the ankle and midfoot. This can have a sudden and profound increase in dorsiflexion of the foot.

   Are there digital deformities or restrictions of movement of the digits at the metatarsophalangeal joints? Examining flexor substitution, flexor stabilization or extensor substitution hammertoes can give insights into foot mechanics that may lead to excessive pressure on the plantar fascia. People always talk about thinking outside of the box. We need to look outside of the heel.

   If there is soft tissue dysfunction or restrictions present and they go uncorrected, then pain will persist. Some of the most commonly restricted tissues include the plantar fascia, gastrocnemius/soleus complex, posterior tibial tendon and posterior ankle joint capsule. One can successfully correct these with any form of myofascial release including deep tissue and cross friction massage or stick rolling. Other options include any of the trademarked soft tissue release/mobilization techniques, such as ASTYM (Performance Dynamics), ART (Active Release Techniques) or the Graston Technique (TherapyCare Resources).

   Taping can also be an effective way to treat soft tissue or joint dysfunction. Classic low-Dye taping can reduce pressure on the plantar fascia in the short term and has an easy and quick application. Taping has many variations, including adding scaphoid felt pads and using Elastoplast instead of athletic tape. All of these can be effective in different practitioners’ hands.

   The navicular sling strapping is another easy to apply taping that often provides almost immediate pain relief. It serves to offload the plantar fascia and the posterior tibial tendon, and may quickly improve gait dysfunction. It is also a cheap, simple test of the possible efficacy of orthotic therapy. If the patient gets significant relief from the taping, then a well molded, supportive orthotic may provide the same relief without the need to apply tape constantly.

In Conclusion

Plantar fasciitis can be a very painful condition that inhibits people from performing their normal day-to-day activities. The vast majority of patients respond well to conservative therapy and never require surgical intervention, but the success of the treatments rely on identifying the causative factor and removing it as a source of the problem. Many of the causes are outside of the heel area so a careful history and a complete lower extremity exam are keys to successful resolution of the symptoms and preventing recurrence.

   Dr. Corwin is an Associate of the American College of Foot and Ankle Surgeons. He is in private practice in Media and Phoenixville, Pa. He is board certified in foot surgery and rearfoot/reconstructive ankle surgery by the American Board of Podiatric Surgery.

   The author acknowledges Michael Groh, PT, DPT, from Excel Physical Therapy and Fitness for his assistance with this article.

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