Conditions and Treatments

Heel Pain

OVERVIEW:

Pain in the heel is one of the most common forms of foot pain in the United States. It can largely be attributed to the stress on the feet caused by daily activities and exercise that magnifies misalignments in the feet, particularly if improperly-fitted shoes are worn.

CAUSES:

Physicians use the terms plantar fasciitis and post-static dyskinesia interchangeably to refer to heel pain.

There are many structures attached to the heel bone (calcaneus). The two structures primarily associated with heel pain are the plantar fascia (band of connective tissue along the bottom of the foot that supports the arch) and the flexor digitorum brevis muscle. Typically, in walking, the arch starts to flatten as the foot absorbs the weight of the body and these structures maintain the arch and stabilize the foot (see Anatomy of the Foot and Ankle). Normally, they accomplish this effortlessly. Excessive exercise and occupations that require people to spend a lot of time on their feet may stretch these structures beyond their limits. This stretching can lead to muscle tears and bone spurs.

Bone spurs on the heel occur when muscle tension (usually on the flexor digitorum) pulls a piece of bone away from the calcaneus. A bone spur usually appears on x-ray as a fishhook-shaped structure. This sharp-edged deformity irritates the nerves in the heel and, combined with the strained muscles, causes heel pain.

Poorly fitted shoes exacerbate the problem further. Many people who work all day in new or ill- fitting shoes experience heel pain the next day. Ill-fitting running shoes may cause pain for weeks after a single run, as can playing 18 holes in improper golf shoes. This does not mean that a $100 pair of sneakers is necessarily better than a pair that costs $50; the fit is what is important.

Sneakers and athletic shoes should fit properly, have plenty of cushioning to absorb shock, and provide support. There are different types of shoes for different sports. This is more than a marketing gimmick. Certain sports, such as tennis, require shoes that provide lateral support and others, such as cross-training, require shoes with a softer sole that conforms to irregular terrain.

Another cause of heel pain is not warming up before exercise. The feet should be stretched by performing heel raises. Stand next to a wall flat-footed and raise the heels so all of the body weight is on the front of the feet and the toes. Then relax and return the heels to the ground. Repeat this procedure 10 to 15 times before exercising to stretch the foot muscles and prevent overstraining.

SIGNS AND SYMPTOMS:

Post-static dyskinesia causes heel pain early in the morning that subsides as the day goes on. This occurs because the muscles are tight in the morning, accentuating the strain on the flexor muscle and, if present, bone spurs. As the day progresses, the muscles stretch and the pain subsides. Post-static dyskinesia means "pain after rest."

TREATMENT:

Heel pain is often difficult to cure. The most conservative treatment is to wear well-cushioned shoes and avoid excessively strenuous exercise. However, with this treatment, it can take months for the pain to subside. A podiatrist can administer a corticosteroid injection to the heel. This treatment is often effective, but can be painful. A technique called ionophoresis, in which the medication is pulled through the skin by an electrical charge, can eliminate the injection and produce similar results.

A device can be worn at night to keep the foot at a 90-degree angle to the leg during sleep. This keeps the muscle stretched throughout the night, so it is not under as much pressure in the morning. This also allows healing to occur in the lengthened position.

If heel pain is intolerable or recurrent, surgery may be an option. The procedure is performed through a small incision in the side or bottom of the foot. The surgeon cuts the fascia and possibly the muscle, depending on which is causing the pain, so it no longer pulls. If a bone spur is present, it is removed. After surgery, it is important to closely monitor changes in the foot. Because the structures that maintained the arch of the foot can no longer function properly, the arch is weaker and may flatten. If this occurs, muscle imbalances can occur and deformities such as hammertoes and bunions may develop. These can be prevented by orthotics to provide extra support and keep the foot properly aligned.

PREVENTION:

Prevention is important because once symptoms develop, treatment often necessitates weeks or months of recuperation. To prevent heel pain, wear shoes that provide proper support. People who wear dress shoes often should invest in a pair that gives adequate support. Brand names and high prices do not guarantee a proper fit. A quality dress shoe should not bend easily in the midfoot at the arch. If it does, it will not provide enough support to maintain the arch when walking.

Most work boots offer good support and have strong arches and well-cushioned heels. Heavily worn work boots may develop patterns on the sole that produce imbalances and detract from their effectiveness. Once a shoe of any type shows noticeable angulation in the heel, it should be replaced. The shoe may cause the foot to land awkwardly and problems can develop.

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