Emphasizing the importance of addressing the cause as well as the symptoms of heel pain, this author shares tips and pearls from his clinical experience on conservative modalities ranging from corticosteroid injections and taping to physical therapy and night splints.
Treating heel pain can be a real challenge. It is very important to get a detailed history from the patient as to the etiology of the heel pain. The vast majority of heel pain results from overuse. When acute injuries become chronic, one should identify and address biomechanical causes. Evaluating the patient’s training, shoe gear and any previous treatment is essential to a successful treatment plan.
Commonly, the diagnosis points to plantar fasciitis. However, remember there are many causes of heel pain and your differential diagnosis could include a calcaneal stress fracture, nerve entrapment/neuritis, calcaneal apophysitis, calcaneal bone cyst, Reiter’s syndrome or a possible tumor. A good history and exam will help pinpoint a diagnosis and direct a subsequent treatment plan.
Heel pain in the athlete is commonly caused by an increase in the intensity and frequency of activity. Often the athlete is adding running to the workout routine and for cross-training workouts. A good history will include the following key points: sudden or gradual onset of pain, localized or diffuse pain, pain intensity (scale of 1-10), duration of pain and what relieves the pain. The patient history also includes any prior history of problems, any previous treatment, any changes in training intensity and frequency, and any changes in athletic footwear.
The problem with using the pain scale is getting the patient to understand the relative number as most patients will say it is a 10. It is sometimes difficult to determine if the pain is mechanical or neurological in nature. Commonly, the pain is insidious in nature and there is no incidence of trauma.
To develop an effective treatment plan, one should consider using what I refer to as a “two pronged” treatment approach for the patient. This approach considers treating the symptoms and treating the cause. Treating the symptoms of pain and inflammation would include any combination of: nonsteroidal anti-inflammatory drugs (NSAIDs); cortisone injection; physical therapy; or cryotherapy. Treating the cause would include any combination of: taping; orthotics; shoe recommendations or modifications; night splints; cross training; and/or modification or restriction of activity.
Too often, a treatment plan will address only one of these areas. For example, the patient receives an injection, which does nothing to address the cause of the heel pain.
I have found taping to be a valuable tool in treating heel pain but it appears to be a lost art. Taping can be therapeutic as well as diagnostic in determining if a patient could benefit from functional orthotics. I like to say, “Orthotics are only as good as the shoes that you put them in.” If shoes are worn out or not recommended for your patient, orthotics will not be as effective in controlling the foot.
The biomechanical exam and gait evaluation are critical to addressing the underlying cause. You need to determine what diagnostic studies are needed to confirm your diagnosis, especially if it does not appear to be your classic plantar fasciitis injury.
To stretch or not to stretch — that is the question. All too often we will recommend stretching to patients for treating heel pain in the acute phase of the injury. Unfortunately, stretching often starts before the area has healed sufficiently. Stretching should not begin until the rehabilitation phase of the injury, after the healing phase has occurred. If stretching starts too early, it creates a vicious cycle and can prolong the healing of the injury.
There is also quite a bit of controversy over the value of stretching so the jury is still out. However, I tend to be a believer in the benefit of stretching both in recovering from an injury as well as helping to prevent injuries. When addressing stretching, one should specifically focus on stretching the calf muscles as well as the plantar fascia for both sides. It should be a gradual approach with slow, long, static stretching that builds up gradually over time as the patient can tolerate. One should avoid rapid, violent stretching (ballistic). I will usually recommend a pre-activity stretch after a brief warm-up and a post-activity stretch after cooling down.
Cross training is a very important aspect of the treatment plan. It is important that patients are able to keep up their level of fitness while recovering from heel pain. Ideally, you can have them use pool therapy, bike or elliptical training to stay in shape and avoid stressing their foot.
Limiting or restricting activity is often difficult, especially for the athlete. One should address the intensity and frequency of activity, especially when it comes to those participating in youth sports. Fortunately, children are often involved in varied activities anyway so cross training is helpful in the treatment plan for youth injuries. Cross training is an essential part of the treatment plan for dealing with high school, college and professional athletes.
It is important to realize that exercise prescription is a major part of dealing with the treatment of heel pain. Prescribing exercise and tailoring it to a specific patient is a talent you should develop. Proper exercise prescription can greatly assist in motivating patients to be actively involved in the treatment and help ensure that their fitness level does not drop off significantly. Improper exercise can prolong the recovery time and increase the rehabilitation period. Return to activity guidelines should be clear to the patient with reasonable goals and expectations.
Corticosteroid injections can be helpful as part of the treatment plan you offer to the patient. I tell the patient the injection can help with the pain and inflammation. This can also be a good alternative for a patient who cannot take NSAIDs.
I inject at the medial aspect at the transition area of the dorsal to plantar skin. This approach can avoid the fat pad inferiorly and the calcaneus superiorly.
I always offer ethyl chloride to help minimize the pain. I penetrate the skin quickly and then slowly inject the heel. It is important to explain to patients that they will feel the cold spray, then a stick and a little burning or discomfort. I will usually inject dexamethasone phosphate or Kenalog (Bristol-Myers Squibb) with bupivacaine. I will do up to three injections depending on how the patient responds to the initial injection but usually one or two injections is sufficient to calm down the heel pain.
I stress that a corticosteroid injection is not a cure, just part of the treatment plan. If the patient does not respond to the injection series, I would consider an oral corticosteroid, such as a Medrol dosing pack. It is pointless to repeat steroid injections when there is little or no response in reducing symptoms. I typically do not offer cortisone injections in the acute phase. Also, I warn the patient of a possible steroid flare-up following the injection, which usually resolves in a short period of time. Be sure to caution the patient to reduce activity following a corticosteroid injection as it can mask the pain during activity and make the condition worse.
Physical therapy can be beneficial in the treatment process and the earlier it begins, the better. There are many modalities that one can prescribe such as icing, massage, ultrasound, iontophoresis, stretching and strengthening exercises.
Remember that physical therapy is a prescription so you need to order the frequency and duration of therapy, and establish specific goals. Physical therapy needs to be at least two to three times per week to be effective. I will usually reassess the patient at three- to four-week intervals. If physical therapy is not helping patients after several weeks, reassess the plan. If patients are progressing well, I will often continue their therapy.
The major goals of physical therapy are to decrease pain and increase function. Patients need to understand treatment expectations. I also like to make sure patients receive home exercises to do so they take an active role in their treatment. It is important to work closely with a physical therapist and athletic trainer in the treatment of heel pain.
Taping should be the key ingredient in treating heel pain that is mechanical in nature. As I said earlier, taping is becoming a lost art but it is therapeutic as well as diagnostic. When one properly applies a low Dye strapping, it can provide dramatic relief of symptoms. Physicians can apply this strapping with accommodative padding, such as a cobra pad or medial longitudinal arch pad. I will typically offer taping to all of my heel pain patients who have a biomechanical cause of the pain, which one typically sees with plantar fasciitis. I always check to make sure the patient has not had any trouble with taping in the past.
I use a pre-tape spray. Using 1-inch anchors and 2-inch strips, I apply the strips in an overlapping fashion from lateral to medial, causing an anti-pronation force. I will apply another anchor and then repeat another series of overlapping straps. Then I apply a retention strap on the dorsum of the foot to secure the tape job.
Ideally, the tape job can last several days. Sometimes I will do a criss-cross strapping under the arch if the patient has a cavus foot type and that will tend to provide better support. Although the tape will stretch some in a short time, the proprioceptive feedback benefit will last much longer.
I allow the patient to take a brief shower and then use a hair dryer to help dry out the tape job. Since I use porous cloth athletic tape, it holds up pretty well for several days to a week if needed. If you are taping the patient multiple times for several weeks, an under-wrap or pre-wrap will help protect the skin.
Taping restricts excessive motion but allows for functional movement. Taping is not a substitute for rehabilitation but rather an adjunct therapy. If patients respond well to taping, it is a good indication that functional orthotics will be a benefit for them. Usually, if the patient does not respond to a low Dye strapping, the problem is most likely not plantar fasciitis.
Functional orthotics can greatly benefit patients who have had heel pain and chronic plantar fasciitis. Typically, I will put them in a flexible orthotic with a deep heel cup, wide plate and rearfoot post. A medial heel skive of 2 to 4 mm is also helpful in patients with extreme pronation. A plantar fascial groove may be needed for patients who have a tight plantar fascia to prevent irritation of the medial arch. The easiest way to check is to maximally pronate the foot and dorsiflex the hallux as a tight medial band will be prominent. Sometimes one can use a cobra pad to help increase the medial arch height and decrease pronatory forces. A prefabricated sports orthotic can also be helpful in the interim but usually the patient will require a prescription custom orthotic because of the benefits of a heel cup and rearfoot posting providing more support. I typically do not use orthotics in acute or sub-acute cases, or with patients who have not postively responded to taping.
Try to avoid the trap of fitting the orthotic to the shoe. I will usually have patients wait to get any new footwear until they have their orthotics to help ensure a good fit. Then I will have patients bring in their new footwear and check for fit and control with the orthotic. I always advise the patient with heel pain to avoid flip-flops or sandals due to lack of support and cushioning. It is surprising how often a patient will be in flip-flops when he is she is being treated for a foot problem.
Night splints are also a good alternative for treatment to help retain the plantar fascia tension by providing constant force. However, patients may not tolerate the night splints for a prolonged period of time. One can set the night splints for positioning with dorsiflexion commonly from 5 to 15 degrees. This reduces the effect of post-static dyskinesia by reducing the effect of shortening of the plantar fascia and intrinsic muscles of the foot.
Proper footwear is essential for the patient with heel pain. Often, part of the cause of heel pain is an improper shoe for that patient. Usually, the proper athletic shoe will be a great benefit. There are many brands and models of shoes out there so it is best to give your patients some qualitative guidelines. Most patients find they have gravitated to a particular brand that tends to fit their foot. However, it is often not the best model or size for them.
Depending upon the foot type and biomechanics, patients will typically need guidance toward one of the following shoes: motion control, stability or cushion shoes. I typically do a shoe exam that checks for heel counter rigidity, midfoot torsion stability and forefoot flexion of the shoe. Ideally, a removable sock liner or inner sole will allow for easy placement of an orthotic and allow the heel area of the orthotic to sit flat in the shoe.
Typically, a pes cavus foot type will do best in a cushion or neutral type of shoe. A pes planus/hyperpronated foot type will need a moderate to maximum motion control shoe. A normal foot type will usually do well with a stability or mild motion control shoe. One needs to address the shoes before even getting to the orthotic stage. At this point, there is no evidence that toning shoes or rocker bottom shoes provide any benefit for dealing with heel pain. The American Academy of Podiatric Sports Medicine has a helpful section on its website (www.aapsm.org ) on athletic footwear recommendations, which can help the practitioner keep current on models and styles.
Have patients try on shoes in the afternoon or evening when their feet will be the largest. Measure patients with a Brannock device while they are standing. Use the measurements as a guide or reference only as different brands can run relatively different sizes. One can also use the shoe fit test to trace the foot and then the shoe, and compare for overlap. Patients should be wearing a similar style of sock. If they have an orthotic device, they should have it in the shoe. There should be a finger width between the end of their longest toe and the shoe. I always have them try on a half size bigger shoe to compare the fit.
I do not recommend breaking in shoes as this tends to break in the feet. Have patients wear the new shoes indoors for a day or two to make sure they feel comfortable. I will then repeat the three-point shoe exam with them to help make sure it is the proper shoe for them. Most patients do best in a running shoe as they offer the best support and cushioning (see “Keys To Ensuring A Good Fit With Athletic Shoes” above).
A two-pronged approach is helpful in treating heel pain. Most heel pain will respond well to conservative care using this approach. Make sure to address biomechanical issues, footwear considerations and return to activity principles. I rely on taping and athletic footwear prescription as the gold standards of my approach to heel pain. Cross training and exercise prescription are also critical to successful rehabilitation. Stretching programs can be helpful, especially in children with calcaneal apophysitis or plantar fasciitis.
When the patient is not responding to conservative treatment measures, consider additional diagnostic tests to identify the cause and rule out some of the other differential diagnoses of heel pain. Extracorporeal shockwave treatments or surgical repair may be necessary. Consider post-treatment orthotics and proper footwear to prevent further problems.
Dr. Dutra is an Assistant Professor in the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt University. He is a podiatric consultant of Intercollegiate Athletics at the University of California. He is a Fellow and Past President of the American Academy of Podiatric Sports Medicine.
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