Heel Pain and heel spurs explained

Heel pain is the most common of all foot complaints. An estimated 400,000 people in Australia suffer from heel pain (or Plantar Fasciitis). Heel spurs are also common, but they are merely a symptom and not the actual cause of heel pain.

(Pain at the back of the heel pain is called Achilles Tendonitis or Bursitis. Young children may suffer from paediatric heel pain or Sever's Disease.)

Symptoms

"I wake up in the morning and feel a sharp, stabbing pain, right in the centre of my heel. After a while the pain subsides and comes back as a dull ache..."

Most people experience pain in the heel with their first steps in the morning, after getting out of bed. It is presented by a sharp stabbing pain at the bottom or front of the heel bone. The pain varies in severity. In most cases, heel pain is more severe following periods of inactivity (e.g. early in the morning or after sitting for a long period).

The pain will diminish throughout the day as the nerves and tissue adjust themselves and become accustomed to the inflamed area. However, after longer periods of inactivity (e.g. sitting at home or driving) heel pain will return stronger and sharper. Some heel pain sufferers may also experience tight calf muscles and achilles tendons.

What causes heel pain and heel spurs?

The most common cause of heel pain and heel spurs is a medical condition called Plantar Fasciitis. This is Latin for "inflammation of Plantar Fascia". The Plantar Fascia is the flat band of fibrous tissue under the foot that connects your heel bone to your toes. It supports the arch of your foot. Normally, the fascia should be flexible and strong. However in many people this is not the case. Due to factors such as weight-gain, age and incorrect foot function (ie. over-pronation) the plantar fascia are stretched out excessively with every step we take. Consequently the ligament starts to pull away from its weakest point: ie. where the fascia inserts into the heel bone (calcaneus).

This constant tension leads to micro-tearing of the tissue and inflammation at the attachment of the plantar fascia and heel bone, causing heel pain. During rest (e.g. when you're asleep or sitting), the plantar fascia tightens and shortens. When getting up body weight is rapidly applied to the foot and the fascia must stretch and quickly lengthen, causing micro-tearing in the fascia. Hence, the stabbing pain with your first steps in the morning or after sitting for a while.

Because of the continuous pulling of the fascia at the heel bone, the body eventually responds by developing a bony growth on the heel bone. This is called a Heel Spur or Calcaneal spur. The spur itself doesn't cause any pain, it's merely a symptom.

Over-stretching of the Plantar Fascia is more likely to happen if:

- you suffer from over-pronation (lowering of the arch when the foot lands)
- you stand/walk on hard surfaces for long periods (because of your job)
- you have put on some weight in recent months/years or you are pregnant
- the muscles and tendons in your feet and legs are tight
- you are over 45

Treatment options for Heel Pain

Today various treatment solutions are available, some more effective than others.

Medical interventions

Cortisone-steroid injections

Cortisone is a powerful anti-inflammatory and when injected directly into the heel it will work almost immediately. However, many patients will have to come back for more injections as relief only lasts a few months, because this treatment method does not address the actual (biomechanical) cause of the inflammation. Because these injections are quite painful, most doctors today will consider other less invasive treament options first.

Shockwave therapy

ESWT (Extra Corporeal Shockwave Treatment) is more common in the USA than in Australia. A specialist targets therapeutic shockwaves to the affected heel area. The shockwaves stimulate a healing response in the affected tissue and ligaments, resulting in reduced inflammation and pain. This treatment may take from 3 to 4 months to be fully effective.

Surgery

In very rare cases plantar fascia surgery is suggested, as a last resort. In this case the surgeon makes an incision into the ligament, partially cutting the plantar fascia to release it. If a heel spur is present, the surgeon will remove it.

What you can do yourself...

Fortunately there's a lot you can do yourself before seeking specialist medical treatment. The self-treatment suggestions below are tried and tested over the years and if you follow them all, you have a good chance of finding relief, especially if your heel pain has come about quite recently (i.e. in the last 3 months).

Rest or reduced activity

Because the ligament around your heel bone is inflamed, you need to give the tissue a chance to recover. The body is very capable of healing itself and overcoming inflammation, provided you give it some rest. Avoid any running, sports, walking distances, walking up or down hills and standing for pro-longed periods for at least 6 weeks.

Completely avoid any barefoot walking on hard tiles and floors, especially first thing in the morning!

Foot and leg exercises

Many people have tightness in their calf muscles and achilles tendons which can hamper our natural walking pattern, placing exces strain on the plantar fascia. Flexible muscles are very important in the treatment and prevention of most foot and leg injuries. You can find a series of useful exercises here..

Ice and Anti-inflammatories

Twice or three times a day, apply an ice pack directly onto the heel and hold it for 5-to 10 minutes. This will help cool down the inflammation and provide temporary pain relief. Anti-inflammatory medications like Ibuprofen (found in Nurofen and Advil) will help decrease the inflammation of the plantar fascia as a result of the tissue micro-tearing. Voltaren Rapid is also a strong anti-inflammatory drug and helpful for temporary pain relief.

Support your arches with orthotics

Most GP's, podiatrists and physiotherapists recommend orthotic insoles to support the arches and re-align the feet. The reason for this, is that orthotics help treat the cause of heel pain (poor foot biomechanics). In most cases heel pain is simply caused by an incorrect walking pattern, which can be restored by wearing an orthotic arch support inside the shoes.

Summary:

Definition: Heel Pain (latin: Plantar Fasciitis)

Symptoms: sharp pain in the heel with first steps in the morning or after resting, subsiding to dull ache

Causes: inflammation of the Plantar Fascia as a result of over-pronation

Treatment: orthotic insoles to correct pronation; special exercises; rest/reduced activity

plantar fasciitis - planter fascitis

How orthotics help with heel pain..

Orthotics are corrective foot devices. They should not be confused with spongy, rubber footbeds, gel heel cups etc. Gel and rubber footbeds may cushion the heels and feet, but they do not provide any biomechanical correction. In fact, gel can do the opposite and make an incorrect walking pattern even more unstable!

Orthotic insoles support the arches and re-align the ankles and lower legs. Many of us have quite normal-looking arches when sitting or even standing. However, it is the impact of walking (and running) that has an effect on the arch and ligaments in the foot. With every step we take the arches lower, placing tension on the plantar fascia, which leads to inflammation at the heel bone. Orthotics support the arches and reduce the tension on the plantar fascia, thereby allowing the inflamed tissue to heal.

To be effective, for most people the orthotic needn't be an expensive, custom-made device... A comprehensive Heel Pain study by the American Orthopaedic Foot and Ankle Society found that by wearing standard orthotics and doing a number of daily exercises, 95% of patients experienced substantial, lasting relief from their heel pain symptoms! Other Heel Pain studies have also shown the benefits of orthotics and exercises in the treatment of heel problems.

Developed by Australian podiatrists, Footlogics support the arches and greatly reduce the tension on the plantar fascia, treating the cause of of heel problems. Plus, a shock-absorbing heel pad helps reduce the impact on the painful heel, providing added relief and walking comfort. Recommended by GP's, podiatrists and physiotherapists, Footlogics orthotics have helped many thousands of heel pain sufferers in Australia and overseas.

Recommended orthotics for Heel pain:
Footlogics Comfort - $32.95 per pair
Footlogics Casual - $29.95 per pair

Heel Pain studies: the effectiveness of orthotic insoles

In recent years a number of studies have been undertaken to measure the effectiveness of orthotic insoles in patients presenting with heel pain, heel spurs or Plantar Fasciitis. Below are short extracts from some of these studies...

Study I

Treatment of Plantar Fasciitis Using Standard “off the shelf “ Foot Orthoses.

Department of Podiatry, Curtin University, Kent Street, Bentley, Perth Western Australia .

Conclusions: Standard orthotics do have a significant effect on plantar fascia symptoms in this patient group. This finding supports the current literature. The results suggest that clinical measures of the foot have little or no value as predictors of the level of plantar fasciitis thickness, level of pain, disability or reduced activity seen in the patient. The navicular drop technique is a reliable foot posture evaluation. However, it would appear to have no correlation with any of the variables measured. Flatter feet do not seem to produce thicker plantar fascia, have more pain, cause greater disability or reduce activity. The only factor that seems to be correlated to plantar fascia thickness is the increase in BMI and patient's weight.

Study II

The American Orthopaedic Foot and Ankle Society (AOFAS) announced today the results of a two-year prospective randomized national study on the treatment of heel pain. The study found inexpensive off-the-shelf shoe inserts to be more effective than plastic custom arch supports in the initial treatment of heel pain (plantar fasciitis). Potentially, this finding could save more than $200 million in health care costs annually.

Heel pain affects over two million Americans annually and is the most common foot problem seen in medical practice. Non-operative care for heel pain provides satisfactory treatment for 90 percent of patients. However, research has not established which initial non-operative care is best. The current study, involving 15 orthopaedic foot and ankle centers, was designed to answer this question.

The investigation, conducted by the AOFAS Heel Pain Study Group, looked at the effectiveness of stretching exercises and orthotic devices in the treatment of heel pain. The researchers examined 236 patients who had no previous treatment for their heel pain and no serious medical problems.

The patients were divided (randomized prospectively) among five treatment groups. One group did only Achilles tendon and plantar fascia stretching exercises. (The plantar fascia is the band of tissue that stretches from the ball of the foot to the heel.) The other four groups used an off-the-shelf orthotic shoe insert along with the stretching exercises. All of the patients were examined by an orthopaedic foot and ankle specialist and asked to fill out an activity and symptom questionnaire. They returned after eight weeks of treatment for a repeat examination and questionnaire.

Seventy-two percent of those who did only Achilles tendon and plantar fascia stretching improved. 95% of those who used orthotic insoles improved.

The study clearly demonstrates that a stretching program plus an inexpensive pharmacy-bought orthotic insole is the best and most cost effective treatment for heel pain," said Glenn Pfeffer, M.D., San Francisco, Chairman of the AOFAS Heel Pain Study Group. "These findings will allow patients and the health care system to save hundreds of millions of dollars each year by avoiding the unnecessary prescription of a rigid custom arch support for the initial treatment of heel pain."

Study III

Journal of Orthopaedic & Sports Physical Therapy, Official Publication of the Orthopaedic and Sports Physical Therapy Sections of the American Physical Therapy Association

The Impact of Foot Orthotics on Pain and Disability for Individuals suffering Plantar Fasciitis

CONCLUSION: Semirigid foot orthoses may significantly reduce pain experienced during walking, and may reduce more global measures of pain and disability for patients with chronic plantar fasciitis. Our results were obtained within a relatively short period of time for subjects who had experienced chronic symptoms associated with plantar fasciitis, and who had used multiple interventions before using the semirigid foot orthotics provided during the study. Semi-rigid foot orthotics similar to the ones used in this study may be a cost-effective intervention for heel pain considering the limited number of clinic visits required to fabricate and adjust the orthotics.