Published Friday, August 13, 2004
by Dr. Leonard E. Vekkos
One of the most common afflictions seen in doctors' offices, heel pain can be a very debilitating condition that affects quality of life activities on a daily basis. The great news is that the majority cases of heel pain, in the experience of this author and physician, can be remedied with conservative care. What must be understood is that heel pain can be an indication of one of five possible causes:
- Biomechanical
- Traumatic
- Neurogical
- Arthritis
- Other causes such as infection and tumors
Because over 95% of the heel pain can be related to the biomechanics or how your foot works and is readily treatable and responsive to conservative care, this is the etiology that I will be addressing in today's' column.
"You arise in the morning and the first steps out of bed are met with severe and sometimes excruciating pain on the bottom of the heel. It forces you to walk holding on to the walls and you find it difficult to put your down on the ground. You shower, get dressed and go downstairs for breakfast and the morning paper. As you prepare for the day or travel to work, you notice the heel feels better and, as long as you are active, you give it no further thought. But you have to sit down sometime during the day, whether it is at lunch or at the end of the day on the train or in the car as you head home. And of course dinner is usually a sit-down episode (for some of us anyway) and you notice as you get up from this resting position and place your foot on the ground, the memories of that morning's heel pain come flooding back as you experience the same excruciating pain. Day in and day out, this becomes the mantra for your existence." Does this sound at all familiar?
This is the typical presentation in our office of a patient with heel pain. Biomechanical heel pain will always be traced back to the way you walk and stand and will be activity related in most cases. It is interesting to note that the pain is typically at the beginning of activity or after rest from activity and NOT during the activity. This is due to the very nature of the structure of your foot. Our feet are composed of 26 bones and over 100 ligaments and tendons. One of the major ligaments is called the plantar fascia and runs along the bottom of your foot from the heel to the ball and attaches to your toes. Likened to a thick rubber band, it is one of the structures responsible for supporting your arch and when stressed will start to pull excessively on the heel, usually on the bottom inside part which becomes very tender. While resting during sleep or while sitting, the ligament contracts back up and when you put pressure on your foot again, it has to be stretched out all over again and the pain cycle repeats itself. However, once stretched out, the pain seems to alleviate and is minimized as long as you are active.
Why does heel pain start at all? Often, it is a change in some aspect of our life that affects our feet. You start walking for exercise, change your shoes to a new style, get a standing job when you used to sit all the time, go from working on carpeting to concrete....any number of changes that will directly affect the pressure brought to bear on the plantar fascia as it struggles to support your arch. And yes...as we get older, the structures that support our feet tend to weaken over time and we will see our feet start to flatten. Ever notice your feet getting bigger as you age? This is why. The flatter the arch, the bigger the foot.
A visit to your foot specialist will be necessary if symptoms persist. The visit will entail taking a complete history of your heel pain, evaluating your foot structure and function and x-rays. It is not uncommon for a heel spur to be found on the x-ray. What has been discovered through studies and research is that the presence of a heel spur is not correlated with the level of pain. Anatomical dissections have found that the heel spur does not attach to the ligament, but to muscles in the foot . Since the pain is associated with inflammation at the attachment of the plantar fascia, it has been concluded that the heel spur, while it may be a sign of how long the condition has been present, it is not causing the pain in the majority of the cases.
In my next column, we will discuss the conservative, non-surgical options in the treatment of heel pain.