Heel pain is the fourth most common reason for patients to visit their family doctor's office. The most common cause of heel pain is plantar fasciitis. There are other causes of heel pain such as rheumatoid arthritis and gout but plantar fasciitis probably makes up about 95 percent of the causes of heel pain.
The plantar fascia is a broad, flat ligament that runs along the bottom of the foot lending the foot support. It is shaped like a trapezoid, being narrower at its attachment to the heel bone then widening as it courses forward toward its insertion at the base of the toes. Patients often present with pain of insidious onset, gradual progression and culminating to a point in which medical attention is sought.
If you’re experiencing these symptoms, or any other symptoms of heel pain, you deserve to find answers and relief as quickly and effectively as possible. Ready to receive heel pain treatment from the best foot doctor San Antonio has to offer? Schedule your first appointment with Dr. Davis today.
There are many causes of heel pain. The first step is to get the right diagnosis.
We see many patients with heel pain in our practice as a San Antonio podiatrist who have had the problem for months, if not years, but have never had a well-defined treatment plan. Such a treatment plan starts with an accurate diagnosis.
Plantar fasciitis, inflammation of the ligament that supports the arch and originates on the heel bone, is the most common cause of heel pain. Plantar fasciitis can be caused by overuse and can be transient, but can often become chronic if the underlying causes are not identified and resolved.
The plantar fascia is the large ligament that supports the arch and structures that support the foot. It is strong but can be damaged over time. The fascia has terrific tensile strength or pulling strength but is not strong when twisted. Twisting or torsional strain of the fascia occurs when overly soft shoes without support are worn or if the patient has biomechanical problems. Overpronation (the foot rolling in too much) or oversupination (the foot rolling out too much) can strain the fascia, causing it to become thickened and painful. The plantar fascia is not visible on X-ray, so the most important first step is to obtain an ultrasound exam in the office to determine its condition.
Treatments for chronic plantar fascia that are aimed at the cause may include use of more stable shoes (shoes with a shank), orthotics, and physical therapy. OTC orthotics or store-purchase orthotics are primarily arch supports and lack the features of prescription orthotics but can be tried first.
Occasionally, the fascia can thicken over time to where it becomes more difficult to treat and has been called "intractable plantar fasciitis." The actual name for that condition is plantar fasciosis, which is a degenerative condition of the fascia. That is readily identified by an ultrasound exam. Plantar fasciosis includes a separate and distinct set of treatments from plantar fasciitis.
That said, plantar fasciitis is not the only cause of heel pain.
Plantar fasciitis causes heel pain that is often worse after rest or after getting out of bed, also known as "first step" pain. A medical term for that is "post-static dyskinesia." Patients with Baxter's neuritis often do not experience first step pain but experience pain that seems to gradually worsen with weight-bearing activities throughout the day.
Heel pain caused by plantar fasciitis generally subsides when one sits down and at night. Heel pain due to Baxter's neuritis may continue after one is off the feet. A burning pain may be encountered or a sharp shooting pain. Patients occasionally locate the pain at the edges of the heel, either the outer or inner edge.
Treatments which are typically effective for plantar fasciitis appear to have only a mild effect on Baxter's neuritis.
Baxter's nerve enters the heel at a spot on the inside of the heel that, when pressed, can send a shooting pain through the heel. There is no specific test for Baxter's neuritis, so the diagnosis is often made clinically. The nerve may appear enlarged or swollen upon imaging by high-resolution diagnostic ultrasound. Another way to help confirm the diagnosis is for the physician to numb the nerve with a very small amount of lidocaine, preferably with the help of diagnostic ultrasound. If the numbing completely resolves the heel pain, that is a strong piece of evidence that Baxter's neuritis is present.
Treatment options for Baxter's neuritis include the "Baxter procedure," which is a surgical nerve release of the nerve, chemical neurolysis, or radiofrequency ablation:
Radiofrequency ablation involves the accurate placement of a very thin probe that looks like a hollow needle into the area of the nerve to be treated. Placement of the probe is verified by ultrasound or fluoroscopic guidance. A very mild current is then generated, and the nerve is stimulated twice. The first type of stimulation is sensory stimulation, in which the patient will note a recreation of the type of symptoms experienced. The second type of stimulation is motor stimulation, in which a lower-frequency current is applied that activates the one motor branch of Baxter's nerve (the nerve to the fifth toe). One can observe the 5th toe gently move or flex. So there is triple verification of accurate placement of the probe: imaging (ultrasound or fluoroscope), sensory stimulation, and motor stimulation. Next, the radiofrequency current is activated and the nerve heated to about 80 degrees C or 170 degrees F for a little over a minute, just enough to deactivate the sensitive pain fibers.
Relief often occurs within a few weeks, and the patient leaves the office with a Band-Aid and standard shoegear. Unlike chemical neurolysis, radiofrequency ablation only needs to be applied in one treatment.
Heel pain is less common in children than adults, and the causes are usually different. It is unusual for plantar fasciitis to occur in youth. The most common cause of heel pain in the approximately 9- to 14-year-old age group is calcaneal apophysitis or Sever's disease.
The heel bone, or calcaneus, has a growth plate. A growth plate is an open area of growing tissue that creates bone growth located at the posterior (back) area where the Achilles tendon attaches. A growth plate is termed an "epiphysis," and a growth plate to which a tendon attaches is known as an "apophysis." Inflammation at the apophysis of the heel bone is called "calcaneal apophysitis."
An x-ray of the heel bone in a child shows two areas of bone, the main part of the heel bone and a portion in the back with "space" in between the two bones. That space gets smaller as the two bones grow toward each other. Eventually, the space between the two bones disappears, and the two bones become one. That occurs between the ages of 13 to 15 although there is some variability.
The area between the "merging" heel bones or calcaneal apophysis appears most sensitive to overuse injury within 18 months to fusion, in Dr. Davis's experience.
Most patients we see with calcaneal apophysitis present with certain factors in common:
Dr. Davis says, "The popularity of school soccer has led to an increase in cases of calcaneal apophysitis in my practice. Soccer shoes provide little protection for the heel and little support."
Here are some potential treatments to try before seeing a pediatric podiatrist:
Seek professional treatment if self-care is not effective. The key issue is to identify the causes of the heel pain and target treatment to alleviate the causes. If there is excessive Achilles tightness or contracture, then a course of manual therapy can be effective. Significant overpronation is treated with a prescription orthotic. We generally use an orthotic design which has a deep heel cup. The heel cup is the portion of the orthotic that surrounds the heel. The orthotic may have a rearfoot post, which is a wedge that stabilizes the heel, neutralizing excessive motion and stress on the growth plate.
Tight or contracted Achilles tendon can lead to plantar fasciitis or heel pain.
The ankle joint allows the foot to move up and down (dorsiflexion and plantarflexion). The foot needs to be able to move up on the leg by about 15 degrees in order to allow normal gait. Upward motion of the foot on the leg is called dorsiflexion. Lack of adequate dorsiflexion range of motion is called functional equinus. The term “equinus” is derived from the Latin “equus” for horse. A horse's hoof points downward without upward motion.
What causes functional equinus?
The Achilles tendon attaches to the back of the heel bone and the plantar fascia attaches to the bottom of the heel bone. A tight Achilles causes tightening of the plantar fascia. Additionally, if the foot cannot adequately dorsiflex (move upward) on the leg as one pushes off, then one must compensate, finding a different way to achieve that motion. The joint beneath the ankle joint is the subtalar joint. The subtalar joint is responsible for side-to-side motion, inversion (turning in), and eversion (turning out). The motion at the subtalar joint is not pure eversion/inversion, but when one turns the foot out, it also moves up (dorsiflexes) a bit. That motion is known as “pronation.” The opposite motion is known as “supination,” which is a combination of inversion and pointing down (plantarflexion). If there is functional equinus, then the foot will compensate by overpronating during push-off (propulsion). Pronation in that manner will lead to a twist of the middle of the foot with each step and a twisting of the fascia. Chronic repetitive twisting of the fascia causes it to become thickened and painful. A rigid shank in the shoe can significantly reduce the problematic twisting or torsion of the fascia.
Patients with functional equinus often tolerate orthotics poorly or obtain inadequate relief from orthotics because such devices attempt to block the compensatory motion needed for the patient to push off. It is necessary to treat the functional equinus before the orthotic can work.
Treatment of functional equinus:
Stress fractures are cracks in bones that occur from chronic repetitive trauma.
It is relatively easy to understand how bones are broken in trauma such as falls or collisions with objects, as there is a readily identifiable event as the culprit. Consider a paperclip that, after being bent several times, will break in two. If it takes 4 bends to break a paperclip, then a paperclip that has been bent three times, that appears to be in one piece, is not a normal paperclip since one more bend will break it. Human bones, when loaded or bent repeatedly beyond their capacity, may form small cracks which can eventually break. The small cracks are generally not visible on X-ray. The difference between bone and the metal of a paperclip is that bone is continually healing or building up in the area of stress. If the building up or repair process exceeds the damage caused by repetitive stress, then there is not an issue.
The human heel strikes the ground at each step with about 1.5 times body weight during normal walking. Running can increase the force to 2 to 3 times body weight. Shoes with poor heel protection, poor running form, shoes with a lack of shanks, or faulty foot mechanics can significantly increase stress and strain on the heel bone. Pain from calcaneal or heel bone stress fractures may cause pain throughout the day, unlike plantar fasciitis, which is more noticeable after arising in the morning or after rest. Swelling or bruising may be present. One simple test is known as the “squeeze test,” in which one can squeeze the bottom portion of the heel bone, which, if painful, may be a sign of a calcaneal stress fracture. Stress fractures of the heel bone, like other stress fractures, are often diagnosed clinically as imaging may not readily reveal the fracture. Radiographs are often negative when stress fractures occur, so early immobilization via CAM walkers (cast boots) or casts may be considered while awaiting more definitive imaging with MRI or CT scans. The good news is that the heel bone tends to heal well once immobilization has been provided. It is important to recognize the underlying causes of the stress fracture and take measures to prevent recurrence.
It is certainly possible for heel pain to have more than one cause in a patient.
We are taught, in our training, the motto: "If you hear hoofbeats, don't think of zebras." That advice means that if a patient has a symptom, always start with the most common cause, not the more "obscure" or exotic causes. It is true that plantar fasciitis represents about 93% of heel pain. Nevertheless, true plantar fasciitis, which is an inflammation of the plantar fascia, is often self-limiting and relatively easy to treat. It is for that reason that podiatrists may not see that much plantar fasciitis. We see patients with heel pain that has persisted and is not self-limited. In other words, the patients we see with heel pain probably represent a population whose heel pain causes go beyond simple plantar fasciitis.
Traditionally, patients who present with heel pain may have an X-ray performed. What does an X-ray show? Bone and joint, but not ligaments, tendons, and nerves. The plantar fascia is a ligament. A ligament can be seen via diagnostic ultrasound or MRI. MRI may be needed under some circumstances but is not used routinely. Office-based diagnostic ultrasound (sonography) is thus the gold standard in the diagnosis of heel pain and should be the first test performed as opposed to x-ray.
High-resolution ultrasound can also allow visualization of nerves with attention to the type of nerve problems that can cause heel pain, such as tarsal tunnel syndrome, medial calcaneal neuritis, and Baxter's neuritis.
It is not uncommon for us to encounter patients in our offices who have had heel pain for many months or even years and are convinced that they have the toughest cases of plantar fasciitis only to discover, upon sonographic exam, that their heel pain is not caused by plantar fasciitis.
Most heel pain is caused by mechanical issues such as heel pain due to plantar fasciitis. There are numerous causes of heel pain, so getting a proper diagnosis is important. Dr. Davis says, "I see a number of patients with heel pain that they believe is caused by plantar fasciitis, but the symptoms are not relieved by common treatments for plantar fasciitis. Such cases often involve other causes of heel pain."
Here is a partial list of additional heel pain causes:
A couch potato probably takes 1000 to 3000 steps per day while an active person may take 10,000 to 30,000 steps per day. Imagine the plantar fascia being over strained or over stretched with each step and that over stretch taking place 30,000 times a day. The cumulative, repetitive stretching of the plantar fascia begins to take its toll and the plantar fascia reacts by thickening and becoming painful.
Dr. Ed Davis at Dr. Ed Davis Podiatry coined the term “Treatment Triad” several years ago. It is a term that describes the long term progress of plantar fasciitis and why different treatments are more effective for different stages of the disease:
The key to relieving plantar fasciitis in the long term is to stop the repeated overstretching of the fascia in gait. This can be accomplished by a foot specialist making a specialized device called an orthotic that is made from a mold of the foot and functions to hold the foot in a position of minimal stress on the plantar fascia.
There are a number of other treatments like cortisone shots but they are for temporary relief only and can have side effects if used incorrectly. A prescription for physical therapy or massage therapy can also provide temporary relief in a safer fashion. A prescription orthotic is like a prescription eyeglass in that it's efficacy depends on the accuracy of the prescription. Placing one's foot in a foam box to capture its shape only serves to capture the foot in the wrong position. It is up to the foot specialist to position the foot in the corrected position, the position that minimizes strain on the plantar fascia and then capturing that corrected shape with a plaster of Paris mold or with newer technology, a three dimensional optical scanner. The mold or "capture" of the corrected foot shape is then sent to a prescription orthotic laboratory where the orthotic is made. The mold is called a negative cast, so the lab has to pour plaster into the negative cast to make a model of the foot. plastic or graphite is then heat molded to the model to make the orthotic.
Orthotics labs self-police themselves through an organization called the Professional Foot Orthotic Lab of America (PFOLA). Many patients have the impression that they will receive the prescription orthotic and that is it. That is actually the start of treatment as the patient becomes accustomed to the beneficial changes in gait and the plantar fasciitis gradually fades into oblivion.
Absolutely, and in fact, we recommend consulting Dr. Davis before you purchase inserts over the counter. Most store bought inserts or “orthotics” are essentially arch supports, which can actually exacerbate symptoms of pain and make it easier for patients to sprain an ankle.
Some of the other common causes of heel pain that Dr. Davis treats include:
If you are looking for the best podiatrist in San Antonio, Texas, you’ve come to the right place. Chronic heel pain and other foot and ankle ailments shouldn’t put you on the sidelines. If you or a loved one are in need of a foot doctor, visit our office at 109 Gallery Circle, Suite 119, San Antonio, Texas 78258, or call us at (210) 490-3668 to get more information.