Heel pain affects over 2 million Americans each year and can be responsible for mild discomfort or even debilitating pain.
The two most common causes of pain in the bottom of the heel, the arch, or both the heel and the arch, are plantar fasciitis and heel spurs.
Plantar fasciitis is an inflammation of the plantar fascia. The plantar fascia is a thick ligamentous/fibrous band on the bottom of the foot that is attached to the heel, and runs forward to insert into the ball of the foot. Plantar fasciitis is a painful inflammation of this band, which usually occurs at its attachment to the heel; however, the inflammation and pain of plantar fasciitis can occur anywhere on the plantar fascia.
A Heel Spur is a piece of calcium or bone that sticks out from the bottom of the heel bone, and lies within the fibers of the plantar fascia. When walking, the spur may apply undue pressure to the plantar fascia. This produces inflammation and pain in the heel, which at times may radiate into the arch.
Plantar fasciitis and heel spur pain usually begins in the bottom of the heel, and frequently radiates into the arch. At times, however, the pain may be felt only in the arch. The pain is most intense when first standing, after any period of rest. Most people with this problem experience their greatest pain in the morning, with the first few steps after sleeping. After several minutes of walking, the pain usually becomes less intense and may disappear completely, only to return later with prolonged walking or standing. If a nerve is irritated due to the swollen plantar fascia, this pain may radiate into the ankle.
In the early stages of Plantar Fasciitis and Heel Spurs, the pain will usually subside quickly with getting off of the foot and resting. As the disease progresses, it may take longer periods of time for the pain to subside.
Each time we take a step forward, all of our body weight first rests on the heel of one foot. As our weight moves forward, the entire foot begins to bear the body's weight, and the foot flattens and this places a great deal of pressure and strain on the plantar fascia. There is very little elasticity to the plantar fascia, so as it stretches only slightly; it pulls on its attachment to the heel. If the foot is properly aligned this pull causes no problems. However, if the foot is "pronated" (the foot rolls outward at the ankle, causing a break down of the inner side of the shoe), the arch falls excessively, and this causes an abnormal stretching of the relatively inflexible plantar fascia, which in turn pulls abnormally hard on the heel.
The same pathology occurs with "supination" (the rolling inward of the foot, causing a break down of the outer side of the shoe). Supinated feet are relatively in flexible; usually have a high arch, and a short or tight plantar fascia. Thus as weight is transferred from the heel to the remainder of the foot, the tight plantar fascia hardly stretches at all, and pulls with great force on its attachment to the heel.
In both cases, the abnormal stress placed on the attachment of the plantar fascia to the heel usually causes pain, inflammation, and possibly swelling. If this process continues, the plantar fascia partially tears away from the heel. The body will fill in this torn area with calcium; eventually it becomes bone, and a heel spur results.
We can think of the longitudinal arch as a shock absorber with body weight and gravity applying downward pressure on the foot or more specifically on the arch. The ground applying plantar pressure causing stress on the fascia bands. When this procedure is repeated daily, it is sometimes thought that an adventitious bursa forms around the area of origination of the fascia at the heel bone. This mechanism is a protective bursa. The pain on the first weight bearing explains this concept of distention of the bursa when non-weight bearing and compression of the bursa on first weight bearing. This theory could explain the first weight bearing pain and relief upon ambulation.
Predisposing Factors: Those factors that increase your chances of developing Plantar Fasciitis and Heel Spurs are:
- History of previous episodes of Plantar Fasciitis or Heel Spur symptoms.
- Presence of Hereditary Biomechanical Foot Defects (those foot abnormalities that one is born with):
- Pronation and Supination that were discussed above.
- Flat Feet (Arches) pull excessively on the Plantar Fascia. As the arch drops, the Plantar Fascia does not become longer, so there is a greater pull on it. This may eventually cause inflammation and pain in the heel or arch.
- High Arches usually occur in feet that have a shortened Plantar Fascia. It is the shortened Plantar Fascia that actually helps to produce an abnormally high arch. When the Plantar Fascia is shorter than normal, there is an excessive pull on it that may eventually cause heel and arch inflammation and pain.
- Short Leg Syndrome that is left untreated. This disease will increase the forces placed on the Plantar Fascia with each step that is taken. The foot on the longer leg carries the body¹s entire weight longer than is normal (it takes longer for the short leg¹s foot to reach the ground). This increases the amount of weight the Plantar Fascia must bear, which increases the stresses on this structure. Because the foot on the short leg needs to fall further to reach the ground, it is continually "slammed" on to the ground. This will increase the force and weight on the Plantar Fascia of that foot. This may cause Plantar Fasciitis and Heel Spurs to form and be painful.
- Lifestyle Patterns that frequently lead to the occurrence of Plantar Fasciitis and Heel Spurs:
- A Lifestyle that requires you to be on your feet for excessively long periods of time. Whether your job requires this or you enjoy weight-bearing leisure activities, the longer you are on your feet, the more common it is for Plantar Fasciitis and Heel Spurs to occur.
- Frequent barefoot walking stresses the Plantar Fascia. Shoes with a supportive arch, well-protected heel, and good sole provide some shock absorption for the Plantar Fascia. Without this shock absorption, Plantar Fasciitis and Heel Spurs may occur.
- Obesity is one of the most consistent conditions associated with Plantar Fasciitis and Heel Spurs. The increased weight places additional stress factors on the longitudinal arch as well as on the heel bone. This appears more pronounced with rather large weight increases over a relatively short period of time. For instance, if a person were to gain 20-30 pounds in a period of a year or so, they may be more prone to developing this problem as the musculature and support mechanisms have not had the ability to adjust to the additional weight gain. A good example of this might be pregnancy. If pregnancy were the case, we could expect a return to normal weight post partum and reduced symptoms.
Custom-made orthotics are one of the most effective conservative treatments for Plantar Fasciitis and Heel Spurs. This has been the treatment of choice for many people suffering with this condition and has proven to be highly effective.
How Custom-Made Orthotics Work: Our custom-made orthotics for Plantar Fasciitis and Heel Spurs are constructed of thin, comfortable, shock-absorbent materials which gently and effectively:
- Stabilize the foot by using uniquely placed wedges, deep heel cups, and "posts" (stabilizers). When the foot is stabilized, it is brought back to a neutral or normal alignment. When the foot is in its normal alignment, pronation and supination are reduced or completely corrected, and the abnormal pull on the Plantar Fascia is alleviated. This will allow the Plantar Fascia to begin to heal. When healing occurs, the pain and inflammation gradually subside.
- Provide the specific amount of arch support that your foot requires. Our custom-made orthotics support not only the arch as a whole, but each individual bone and joint that forms the arch. Whether your arch is flat or abnormally high, our custom-made orthotics will provide the support that you need. When the arch is properly supported, the Plantar Fascia is protected and healing can begin.
- Aid in shock absorption. The primary shock absorbers of our feet, and therefore our body, are the Plantar Fascia and the arch. To aid these structures, we construct our custom-made orthotics so that they provide semi-flexible support to the arch by "giving" to absorb the shock of each step, rather than our foot absorbing the shock (our orthotics act in the same way a shock absorber does on an automobile). When your weight is removed from the orthotic, the arch returns to its original height since the material we use has a built-in "memory." This action will help to keep the Plantar Fascia and arch healthy and pain free.
- Cushion the heel. Our custom-made orthotics use thin, cushiony, durable, materials to cushion and protect the heel. This helps to alleviate painful heels.
When these things are achieved, the inflammation and pain of Plantar Fasciitis and Heel Spurs will gradually subside. Custom-made orthotics is also very effective in preventing recurrences of these painful problems.
Our Custom-Made Orthotics for Plantar Fasciitis and Heel Spurs are constructed from the impressions of your feet that you make with our Foam Impression Kit. Using these impressions and the information you provide us, we design and construct a pair of orthotics that will help to stabilize your feet, reduce pronation or supination, reduce the abnormal pull on your Plantar Fascia, cushion the heel, and help to alleviate your foot pain. These orthotics will fit in most shoes with a heel height up to 1 1/2 inches.
- Ossur Airform Night Splint: While custom-made orthotics provides treatment for Plantar Fasciitis and Heel Spurs during the day, The Ossur Night Splint helps to treat these problems while we sleep. This uniquely comfortable and effective night splint stretches the Plantar Fascia while sleeping. Plantar Fasciitis and Heel Spur pain are usually worse with the first steps in the morning. This is due to the Plantar Fascia tightening up, or contracting while we sleep. To prevent these pain producing contractures of the plantar fascia, the foot must be held in its normal or neutral position while we sleep. This optimal position of the foot is maintained with our comfortable and supportive Night Splint. When foot contractures are prevented during sleep, the "first step pains" of Plantar Fasciitis and Heel Spurs will gradually subside
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The following self-help treatments have been found to be most effective when used in conjunction with our Custom-Made Orthotics or other helpful products:
- Rest your foot. Reduce the amount of weight-bearing activities you participate in. Get off of your feet and elevate them. This will allow healing to begin.
- Apply ice to your foot. Applications of ice packs that provide a comfortable cooling to the heel and arch (not a freezing cold) will help reduce pain, swelling, and inflammation. Apply the ice to the heel and arch (not the toes). Make sure it is comfortable, and leave on your foot for about 20 minutes, 3 times a day. If you have any medical problems such as diabetes, poor circulation, etc., discuss the use of ice with your doctor before applying the ice. ActiveWrap allows you to apply comfortable cold therapy to your foot without messy ice cubes. Use while on the "go."
- Do not walk with bare feet. Always protect your heels, arches, and plantar fascia with good supportive shoes. Orthaheel Orthotic Flip Flops For Men and Women are designed for walking comfort with built in orthotic footbeds that help reduce foot pain from plantar fasciitis. Use in the house or on the beach.
- Stretch the Plantar Fascia while sleeping. Plantar Fasciitis and Heel Spur pain is usually worse with the first steps in the morning. This is due to the Plantar Fascia tightening up, or contracting while we sleep. To prevent these pain producing contractures of the plantar fascia, the foot must be held in its normal or neutral position while we sleep. This optimal position of the foot is maintained with our comfortable and supportive Night Splint. When foot contractures are prevented during sleep, the "first step pains" Plantar Fasciitis and Heel Spurs will gradually subside.
- Stretch the Plantar Fascia during the day. Even though the Plantar Fascia is a thick tissue band with very little "give" to it, with the proper care (a Night Splint and the following exercises) it can be stretched a small amount. By stretching the Plantar Fascia even a bit, its abnormal pull on the heel is reduced. This will help to reduce pain and inflammation in the heel and arch. Two of the most effective exercises recommended are:
- Before stepping down, especially after sleeping or resting, stretch the arch of the foot by stretching your legs out in front of you (do not bend the knee). Place a towel around the ball of the foot. Slowly pull on the ends of the towel, pulling the toes and ball of the foot back as far as is comfortable. Hold the foot in this position for ten seconds. Repeat at least ten times. You should feel a pull on the bottom of the foot, especially in the arch. This stretches the plantar fascia, and reduces its pull on the heel.
- Stand about 2 to 3 feet from a wall. Lean forward with your hands against the wall. With the painful foot behind, place the other foot forward. Press against the wall, shifting weight over the front foot, while straightening the back leg. Keep the heel of the back foot on the floor and feel the stretch in the heel, Achilles tendon, and calf. Hold this position for ten seconds. Repeat at least ten times, and try to do this three times a day.
Stretching Aid: StretchRite makes it easy to stretch the foot and plantar fascia.
If you are unsure of the nature of your foot problem, if your pain is intense and does not subside, if you are a diabetic or have other medical problems, if your pain is due to an injury, if an open sore is present, if a mass can be felt, or if you think that you may have an infection, we suggest that before beginning any of the above treatments you consult with your doctor.
If conservative treatments fail, and the symptoms of plantar fasciitis have not been relieved, the doctor may recommend one of the following treatments:
Injections of Corticosteroids (Cortisone Injections): Cortisone, or corticosteroids, is medications that reduce inflammation. Cortisone is usually mixed with local anesthetics and injected into the plantar fascia where it attaches to the heel bone. In many cases this reduces the inflammation present and allows the plantar fascia to begin healing. Local injections of corticosteroids may provide temporary or permanent relief. Recurrence of symptoms may be lessened by combining steroid injections with other forms of treatment such as orthotics, changes in shoe gear, weight loss, stretching exercises, and rest. Repeated cortisone injections may result in rupture of the plantar fascia, thinning of the heel's fat pad, and other tissue changes.
Extracorporeal Shockwave Therapy (ESWT): Extracorporeal Shock Wave Therapy (ESWT) devices generate pulses of high-pressure sound that travel through the skin. For reasons that are not fully understood, soft tissue and bone that are subjected to these pulses of high-pressure energy heal back stronger. There is both a high-energy and low-energy form of ESWT; and both forms of shock wave therapy can be used in the treatment of plantar fasciitis. Research studies indicate ESWT is a safe and effective treatment option for plantar fasciitis. The recovery period is shorter than traditional invasive surgery and the procedure eliminates many of the risks associated with traditional surgery.
Surgery: Most studies indicate that 95% of those afflicted with plantar fasciitis are able to relieve their heel pain with nonsurgical treatments. If you are one of the few people whose symptoms don't improve with other treatments, your doctor may recommend plantar fascia release surgery. Plantar fascia release involves cutting part of the plantar fascia ligament in order to release the tension and relieve the inflammation of the ligament. Overall, the success rate of surgical release is 70 to 90 percent in patients with plantar fasciitis. While the success rate is very high following surgery, one should be aware that there is often a prolonged postoperative period of discomfort similar to the discomfort experienced prior to surgery. This pain usually will abate within 2-3 months. One should always be sure to understand all the risks associated with any surgery they are considering.