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A Stepwise Approach To Treating Chronic Heel Pain

   Given the common incidence of heel pain, patients may present to the office with symptoms that have been present anywhere between two or three weeks to perhaps two or three years. Often, these patients have already consulted with another clinician who had an incorrect approach to treatment. When the pain does not resolve, the patient may feel that he or she has to undergo an unnecessary surgical procedure.    This is unfortunate as the problem may be due to improper care. If the treating clinician does not implement the proper treatment plan, including follow-up and long-term care, the patient’s condition may not resolve. As podiatrists, we must realize that patients come to see us because they have “acute” foot pain. Merely fitting them with a pair of orthotics will not suffice as treatment. We are acute care physicians of the foot and ankle. If we don’t relieve acute foot pain immediately, we are not offering the best of our acute knowledge and care skills that have allowed our profession to maintain its unique role in the medical arena.    Treating patients conservatively but aggressively until symptoms disappear and ensuring the proper progression of care are of utmost importance. This will help facilitate patient satisfaction and perhaps improved revenue as a happy and healthy patient is a good referral source. Accordingly, let us take a closer look at potential etiologies, heel pain symptomatology and the appropriate progression of care for these patients.    In regard to typical causes of heel pain, there may be an underlying biomechanical foot abnormality. Typically, this involves pronatory issues at the subtalar joint or midtarsal joint. In regard to tightness in the gastrocnemius-soleus complex, this may be due to pronated flat feet. Poor shoe choices, incorrect sizes or instability in the shoes can also contribute to heel pain. Increasing activity at home or work or within the exercise regimen are other factors to consider. Increased body weight or carrying heavy loads are other causal factors.    As far as presentation goes, patients typically experience pain when they get up in the morning but the pain may ease up after a short time. They may relate that their pain becomes worse with increased activity at home or work or with athletic activity. Pain typically improves with supportive shoes but becomes worse with less supportive shoes or when patients go barefoot.    Patients with heel pain typically may typically present with occasional calf cramps or soreness/tightness in the gastroc-soleus complex. Presentation may also include lateral column foot pain secondary to compensation via supination of the foot.    In addition to typical presentations, some patients with heel pain may present with atypical presentations such as swelling of foot or the ankle or ecchymosis around the heel. Some may also experience numbness or tingling of the foot or severe burning on the plantar foot. Concomitant low back pain along with sciatica/radicular pain is an atypical presentation. Patients may also experience non-weightbearing pain or pain that wakes them up at night.    If any of these atypical signs and symptoms appear but quickly resolve with the first treatment, they may be related to compensation factors. Keep an eye out for resurfacing symptoms. If these or any other non-traditional symptoms continue and the heel pain does not resolve quickly, reconsider the differential diagnosis.

A Guide To The Differential Diagnosis Of Chronic Heel Pain

The differential diagnosis of heel pain includes the following:    • Plantar fascia tear (linear or horizontal, seen on MRI)    • Plantar fibroma    • Bursitis    • Trauma or loss of fat pad with fibrous/scar tissue (seen on MRI)    • Tarsal tunnel syndrome    • Medial calcaneal branch neuritis    • Low back sciatica or radicular pain    • Stress fracture of calcaneus    • Fracture of spur (bone edema seen on MRI)    • Arthritic conditions (Reiter’s syndrome, gout, etc.)    • Myofascial conditions (fibromyalgia, muscle trigger points)    • Tumors (seen on MRI)    • Psychological issues, chronic pain syndrome

How The Initial Treatment Recipe Can Benefit Patients

   When treating heel pain, one must be aggressive and conservative. The goal for the first follow-up visit is at least 60 to 80 percent improvement. It is imperative to explain the treatment approach thoroughly to each patient with a particular emphasis on the patient’s role in following the treatment “recipe.” No substitutions or revisions to the recipe are allowed. Explaining the condition and providing a written handout to the patient can go a long way toward facilitating compliance and optimal results.    For the first visit, instruct the patient to apply ice two times a day. In terms of medications, prescribe an appropriate NSAID and administer a corticosteroid injection using a combination of acetate and phosphate with lidocaine.    I also encourage patients to use a longitudinal metatarsal arch pad (L&M). I prefer a removable style that is made with 1/4 inch of wool felt and Elastoplast tape. The patient must wear this all the time with no exceptions other than showering and sleeping. Patients may wash the pad and dry it by hand or machine. Prefabricated insoles do not work as well due to shoe gear and compliance issues.    When giving these first visit recommendations to patients, I also emphasize stretching the gastrocnemius muscle with the knee straight and stretching the soleus muscle with the knee bent two to three times a day. They should do this exercise gently and without pain.    For active or athletic patients, emphasize the avoidance of running, jumping or fitness walking. Patients may participate in cross-training activities such as biking and swimming.

Emphasizing The Importance Of Appropriate Footwear

   Excellent shoe support is important and patients should preferably wear running shoes as much as possible, especially in the home. Women may wear moderate heels for dress and men should wear tie shoes only. These patients should not go barefoot and should not wear flip-flops, sandals or clogs. They should also be wary of unsupportive loafers. Be very adamant about the importance of appropriate shoe gear as it will make or break this treatment recipe.    Keep a Brannock device in the office and measure each foot. Look at the shoes the patients wear into your office. Ask them to bring their gym shoes and evaluate them to see if there is too much flexibility in the shank of the shoe. Have the patient try on the shoe and use a thumb to measure how much toe box room he or she has in the shoe.    Make shoe recommendations for patients and direct them to the proper shoe store for running or dress shoes. Many local shoe stores will welcome the referrals and may give referred patients a small discount as well. If possible, consider having some casual or running shoe selections available at the office. Many podiatry shoe suppliers have fast and easy ordering capabilities so DPMs can sell shoes directly to patients from the office.    Treating heel pain successfully entails knowing how to fit shoes and where to send patients to buy them. This has a significant impact when it comes to facilitating compliance.    Always take all orthotics out of the patient’s shoes. Quite often, a firm device will irritate the plantar fascia due to restricting the compensation at the midtarsal joint for the tightness in the gastroc-soleus complex. The L&M pad will replace this.

Treating Patients At The First Follow-Up Visit

   Expect 60 to 80 percent improvement on the second visit. Staff should preferably schedule the follow-up visit at two weeks and no later than three weeks. If more than three weeks elapse between visits, compliance decreases and pain increases. Emphasizing initial control over the patient’s treatment plan is key. The following is a guide to treating three patients who have different levels of progress after the first visit:    Patient A. For a patient who has at least 60 to 80 percent improvement, the DPM and the patient have done a good job. Repeat the same exact “recipe” one more time and follow up in two weeks.    Patient B. If the patient only has 30 to 60 percent improvement, repeat the recipe once more and add one or two more treatment modalities. These modalities can include ultrasound, iontophoresis, electric stimulation or another appropriate physical therapy modality. Do this two to three times per week. Consider a night splint as the second additional treatment modality. Follow up in two weeks.    Patient C. When a patient only demonstrates 20 to 30 percent improvement but promises that he or she was compliant, start thinking about the differential diagnosis list. Repeat the recipe one more time. Make sure that you have plain film X-rays and consider pursuing a diagnostic ultrasound or MRI. If this patient has any hint of low back pathology, refer him or her to a local chiropractor for a thorough lumbar spine exam. If this patient was simply non-compliant, get control again and reemphasize the importance of adhering to the recipe. Repeat the treatment recipe and follow-up in two weeks.

Key Considerations At The Second Follow-Up Visit

   Patient A. At the second follow-up, if a patient demonstrates at least 80 to 90 percent improvement, the DPM and patient have again succeeded. Repeat the mechanical part of the treatment recipe again. This includes padding, proper shoes and stretching. Use ice and NSAIDs only as needed. One may add a night splint or physical therapy modalities as needed if the patient is impatient. However, be firm about the patient continuing to avoid running, jumping and/or fitness walking until he or she has 100 percent improvement. Stay positive though because this patient is doing great.    Only at this time is it proper to discuss and cast for orthotics. The initial goal is to relieve the patient’s “acute” pain. As mentioned earlier, putting a patient into an orthotic device before the foot is at least 90 percent improved will quite often backfire. A firmer device will cause increased pain, partly due to the restriction of midtarsal joint pronatory compensation for the tight gastrocsoleus complex. Orthotics are never an “acute” care treatment for heel pain. Use them for the long-term care and future prevention of heel pain. If the patient already has an orthotic, this is the time to reevaluate the orthotics and/or refurbish them with enhanced padding. Also consider recommending a second pair for dress shoes.    Patient B. If a patient is now 80 to 90 percent improved, proceed with Patient A’s protocol. If this patient has 60 to 70 percent improvement, consider a third corticosteroid injection, continue with the original recipe and pursue appropriate imaging if suspicious of any tears or other complications. Continue with physical therapy modalities and perhaps proceed to “formal” physical therapy. One may also add massage therapy and other alternative treatments such as acupuncture, magnetic therapy and homeopathic Traumeel injections. These injections work well in the plantar fascia, bursas and/or trigger points in the abductor hallucis muscle belly. This patient may be discouraged but stay positive and supportive, and try to keep him or her motivated. Although the patient may be impatient, do not let him or her run, jump or do any fitness walking.    Patient C. Some patients may have not improved or demonstrate only 20 to 30 percent improvement, and still maintain they have been compliant. These patients do not have “classic” plantar fasciitis. Do not proceed with a third corticosteroid injection. Do not proceed with orthotics because they will not work if the padding and shoe gear changes did not work.    If one did not pursue imaging previously, proceed now with the imaging modality of choice. Work up the lumbar diagnosis with the chiropractor and/or look into nerve conduction and electromyogram testing. Consider blood work if you are suspicious of arthritic conditions. Have the patient wear a walking, below-knee boot for three to six weeks with a lot of arch and heel padding. Definitely try alternative care such as acupuncture, massage, Traumeel injections and/or “formal” physical therapy at a center convenient for the patient. Reassure the patient and make this a partnership with the patient and the other practitioners.

What You Should Look For At The Third Follow-Up Visit

   Patient A. At the third visit, for a patient showing 90 to 100 percent improvement, have him or her slowly break in the new orthotics whether they are custom or prefabricated. If the patient has not experienced any pain with everyday activities for at least two weeks, let him or her slowly start a walking/running program. However, do not let him or her walk or run with the new orthotics for two to three weeks. Tell the patient to only use the L&M padding while walking or running.    Patient B. If this patient has improved 80 to 90 percent, continue with Patient A’s protocol. If he or she demonstrates 60 to 70 percent improvement, then continue and/or increase the alternative and physical therapy treatments. Perform the third corticosteroid injection if you did not do this previously. Consider appropriate radiographic imaging if this has not already been done. Re-question these patients about what shoe gear they wear during the day and at home. Also follow up with them about their work, home and athletic activity. Slow improvement may be due to these aforementioned factors. Stay positive with the patient that this condition will resolve.    Patient C. If this patient starts to improve, continue with the walking boot and the other treatments mentioned. Continue to stay positive and stay in control of his or her treatment plan. If you suspect an alternate condition, reexamine the differential diagnosis.    If this patient still has not improved and there are no positive findings on lab work, testing and or imaging, then consider a referral to a mental health specialist, primary care physician and/or pain specialist. There can be emotional and psychological factors with chronic pain and I have seen foot pain resolve after psychological counseling with a specialist. This patient will probably not have good relief with surgical treatment. Always choose surgical patients carefully, especially if you suspect mental health issues.

Weighing The Treatment Options At The Fourth Follow-Up Visit

   Patient A. Follow up on the orthotics. If the patient is still doing well, discharge the patient but remind him or her to continue to stretch and use the proper shoes and orthotics. Have patients continue to ease into their athletic programs. Make sure patients understand the long-term maintenance and refurbishing of orthotics.    Patient B. If this patient is still improving, continue the mechanical part of the recipe. Add or continue the various modalities as needed. When these patients reach the point of 80 to 90 percent improvement, cast for orthotics. Do not let the patient run, jump or walk for fitness.    Patient C. If this patient is still improving slowly, continue with the original treatment recipe and walking boot as needed. If a fourth injection is necessary, try the Traumeel homeopathic remedy. This will give good antiinflammatory relief and one can repeat them regularly without concern of damage to the tissue. Continue to add modalities, such as ultrasound, electric stimulation, iontophoresis and phonophoresis, two to three times a week. Keep a close eye on the patient’s activity level and shoe gear if he or she is out of the boot. Stay positive. I believe these patients may benefit the most with surgical intervention.    Use at least three months of this treatment recipe prior to shockwave therapy and use at least six months of the treatment recipe prior to traditional surgical release.

In Conclusion

   One must treat heel pain aggressively and conservatively, emphasizing appropriate control over the treatment plan and timely follow-up. It is imperative that DPMs always start with the “first visit recipe” for acute plantar fasciitis. If return visits produce similar results with the majority of patients, the “atypical” patient will really stand out, allowing one to reconsider the differential diagnosis. Dr. Schoene is a certified athletic trainer and a Fellow of the American Academy of Podiatric Sports Medicine. Dr. Schoene is a Fellow of the American College of Foot and Ankle Surgeons, and is board certified by the American Board of Podiatric Surgery.

By Lisa M. Schoene, DPM, ATC
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