Plantar Fasciitis and Other Causes of Heel Pain
Plantar Fasciitis and Other Causes of Heel Pain
- STEPHEN L. BARRETT, D.P.M.
- Spring, Texas
- ROBERT O'MALLEY, D.P.M.
- Columbia Kingwood Hospital
- Kingwood, Texas
The most common cause of heel pain is
plantar fasciitis. It is usually caused by a biomechanical imbalance resulting
in tension along the plantar fascia. The diagnosis is typically based on the
history and the finding of localized tenderness. Treatment consists of medial
arch support, anti-inflammatory medications, ice massage and stretching.
Corticosteroid injections and casting may also be tried. Surgical fasciotomy
should be reserved for use in patients in whom conservative measures have
failed despite correction of biomechanical abnormalities. Heel pain may also
have a neurologic, traumatic or systemic origin.
Plantar fasciitis, the most
common cause of heel pain, may have several different clinical presentations.
Although pain may occur along the entire course of the plantar fascia, it is
usually limited to the inferior medial aspect of the calcaneus, at the medial
process of the calcaneal tubercle. This bony prominence serves as the point of
origin of the anatomic central band of the plantar fascia and the abductor
hallucis, flexor digitorum brevis and abductor digiti minimi muscles.
Plantar fasciitis is often referred to as "heel spur syndrome" in the
literature and the medical community, but the label is a misnomer. This vague
and nonspecific term incorrectly suggests that osseous "spurs" (inferior
calcaneal exostoses) are the cause of pain rather than an incidental
radiographic finding. There is no correlation between pain and the presence or
absence of exostoses,1 and excision of a spur
is not part of the usual surgery for plantar fasciitis.2 Plantar fasciitis occurs in both men and women,
but is more common in the latter. Its incidence and severity correlate strongly
with obesity.
Etiology
Most cases of plantar fasciitis are the result of a biomechanical
fault that causes abnormal pronation. For example, a patient with a flexible
rearfoot varus may at first appear to have a normal foot structure but, on
weight-bearing, may display significant pronation. The talus will plantar flex
and adduct as the patient stands, while the calcaneus everts. This pronation
significantly increases tension on the plantar fascia.
Other conditions, such as tibia vara, ankle equinus, rearfoot varus,
forefoot varus, compensated forefoot valgus and limb length inequality, can
cause an abnormal pronatory force. Increased pronation with a collapse produces
additional stress on the anatomic central band of the plantar fascia and may
ultimately lead to plantar fasciitis.2,3 This
is understandable since the weakest point of the plantar fascia is its origin,
not its substance (because of the high tensile strength of the fascial fibers
themselves).4
Presenting Symptoms
Patients usually describe pain in the heel on taking the first
several steps in the morning, with the symptoms lessening as walking continues.
They frequently relate that the pain is localized to an area that the examiner
identifies as the medial calcaneal tubercle. The pain is usually insidious,
with no history of acute trauma. Many patients state that they believe the
condition to be the result of a stone bruise or a recent increase in daily
activity. It is not unusual for a patient to endure the symptoms and try to
relieve them with home remedies for many years before seeking medical
treatment.
Diagnosis
Even in this age of modern technology, the diagnosis of plantar
fasciitis is based mainly on the medical history and clinical presentation.
Direct palpation of the medial calcaneal tubercle often causes severe pain.
The pain is generally localized at the origin of the
anatomic central band of the plantar fascia, with no significant pain on
compression of the calcaneus from a medial to a lateral direction. Standard
weight-bearing radiographs in the lateral and anteroposterior projection
demonstrate the biomechanical character of the hindfoot and forefoot, and may
show other osseous abnormalities such as fractures, tumors or rheumatoid
arthritis in the calcaneus. However, radiographs usually serve only as an aid
to confirm the clinician's diagnosis.
Conservative Treatment
Conservative treatment of plantar fasciitis should address the
inflammatory component that causes the discomfort and the biomechanical factors
that produce the disorder. Patient education is imperative. Patients must
understand the etiology of their pain, including the biomechanical factors that
caused their symptoms. They should learn about home therapy that may relieve
some discomfort and about recommended changes in daily activities, such as
wearing appropriate athletic shoes with a significant medial arch while
walking. Patients whose symptoms are associated with a recent increase in
exercise should adopt a less strenuous regimen until the plantar fasciitis
resolves.
The patient is fitted with a removable longitudinal metatarsal pad
during the first visit. This pad, which is created from felt, 1Ž4-in
thick, extends from the distal aspect of the medial calcaneal tubercle to about
0.5 cm proximal to the five metatarsal heads. The clinician should skive (cut
or bevel) this pad so that its greatest thickness is under the medial aspect of
the arch, as opposed to the lateral aspect of the foot. This pad serves as a
temporary medial arch support to decrease pronation during midstance of the
gait cycle.
Other clinicians favor placing a medial arch pad directly against the
patient's skin and taping the patient's foot from a plantar medial to a plantar
lateral direction using 3-in wide tape. These temporary devices provide greater
biomechanical support than over-the-counter heel cups or heel pads. If a
patient has significant plantar fasciitis pain secondary to a limb-length
inequality or unilateral ankle equinus, a simple 1/4-in heel lift in the shoe
of the affected foot may provide temporary relief.
Stretching the Achilles tendon is beneficial as adjunctive therapy
for plantar fasciitis. The patient is instructed to face a wall with one foot
approximately 6 in from the wall and the other foot about 2 ft from the wall,
and then lean toward the wall while keeping both heels on the floor. This
exercise stretches the heel cord of the limb that is farther from the wall. It
should be performed with both legs forward for two minutes each, three to five
times daily. This stretching program should be continued for six to eight
weeks, after which time the patient is reevaluated.
 |
| Orthotic
devices that counteract pronation and disperse heel strike forces are a key
component of treatment for plantar fasciitis. |
|
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Each night for 10 to 14 days, the patient should apply an ice pack to
the plantar aspect of the heel 15 to 20 minutes before going to bed. An
alternative approach is to massage the plantar fascia with an ice block (made
up of water frozen in a paper cup) for 15 minutes per day for two weeks.
It is often advantageous for patients with no contraindication to
take a nonsteroidal anti-inflammatory drug (NSAID) for six to eight weeks. We
believe that corticosteroid injections should be avoided in the initial
treatment of plantar fasciitis; we use them only as supplemental treatment in
patients who have resistant chronic plantar fasciitis after achieving adequate
biomechanical control. These injections may provide only temporary relief and
can cause a loss of the plantar fat pad if used injudiciously. Typically, 3.0
mL of an equal mixture of 1 percent lidocaine, 0.5 percent marcaine and 1 mL of
triamcinolone (40 mg per mL) is injected around the medial process of the
calcaneal tuberosity. Solutions containing epinephrine are not used.
Radiographic guidance of injection placement may aid the inexperienced
practitioner.
Night splints that maintain the foot at an angle of 90 degrees or
more to the ankle have recently been used as adjunctive therapy for plantar
fasciitis. These orthoses prevent contraction of the plantar fascia while the
patient sleeps. One study5 showed relief of
recalcitrant plantar fasciitis pain in 83 percent of patients treated with such
splints.
Orthotic devices are the mainstay of ongoing conservative treatment
for patients with plantar fasciitis. The biomechanical factors that cause the
abnormal pronatory forces stressing the medial band of the plantar fascia must
be corrected. Patients with pes cavus feet may benefit from using a flexible
orthotic device with an additional heel cushion. This prescription orthosis can
disperse some of the force experienced on heel strike, while maintaining
biomechanical support for propulsion. Prescription orthoses provide long-term
relief by reducing abnormal stress on the plantar fascia.
The clinician should perform a complete biomechanical examination,
checking the range of motion of the first metatarsophalangeal, midtarsal,
subtalar and ankle joints, as well as the forefoot-to-rearfoot relationship, to
adequately correct for any biomechanical abnormalities. To make the orthosis,
the clinician should cast the foot with the subtalar joint in the neutral
position, neither inverted nor everted. Casting performed in this position
captures the foot deformity and allows for proper biomechanical control. A
properly casted orthosis will provide biomechanical support and diminish the
abnormal compensatory force that may subsequently cause plantar heel pain.
Family physicians who do not elect to learn and utilize the skills necessary to
provide this type of care may refer patients to podiatrists or orthopedic
surgeons with an interest in such treatment.
Some clinicians advocate the use of a short-leg walking cast for
several weeks as a final conservative step in the treatment of plantar
fasciitis. In one study,6 a short-leg cast
worn for a minimum of three weeks was found to be an effective form of
treatment for chronic plantar heel pain.
The Authors
STEPHEN L. BARRETT, D.P.M.,
has a private practice in podiatry in
Spring, Tex. Dr. Barrett graduated from the Dr. William M. Scholl College of
Podiatric Medicine, in Chicago. In addition to directing his practice, Dr.
Barrett lectures extensively and conducts training courses to instruct surgeons
in his endoscopic techniques.
ROBERT O'MALLEY, D.P.M.,
is currently in private practice in
Wilmington, N.C. After graduating from the Dr. William M. Scholl College of
Podiatric Medicine, he completed a residency at the Houston (Texas) Podiatric
Foundation.
Address correspondence to Stephen L.
Barrett, D.P.M., Advanced Foot Care, 25227 Borough Park Dr., Spring, TX 77380.
Reprints are not available from the authors.
