Patient Education

© 1999-2001 by Seth A. Rubenstein, D.P.M.

In the vast majority of cases, heel pain is produced by a strain of the plantar fascia. The plantar fascia is a tight, nonelastic ligament that stretches from the bottom of the heel bone out toward the ball of the foot. The ligament can become overstretched, producing "microscopic tears" primarily in the heel region (see image 1 below).

Such injury can be the result of increased weightbearing producing a strain on the ligament, poorly supportive shoes, increased weight, overt trauma or tight posterior leg muscle groups. When present for a prolonged period of time, traction at the origin of the ligament (at the heel bone) can produce growth of bone in the direction of pull, this is frequently seen as a "spur" on x-ray.

 

---

---

X-rays are usually obtained to rule out other causes of heel pain such as fracture or tumor. The bone spur does not produce pain unless it is oriented in a plantar grade fashion (toward the ground) or fractured.

 

Image 1                                                                                   Image 2

Pain associated with this condition is the result of the healing process. When standing there is too much strain on the ligament to allow for healing to take place. As such, the body must wait until one is off weightbearing (sitting in a chair or lying down in bed at night). At this time there is increased blood flow to the injured portion producing focal swelling and inflammation.

Such healing takes several days to weeks to mend, however, a mere eight hours later one sits up and steps out of bed. At this time there is an immediate re-stretching of the ligament, as well as pressure against the swollen inflamed region (bottom of the heel), both of which produce acute pain. With walking, the ligament stretches back out and swelling may be milked out of the region producing some relief of pain, however, the injury itself persists.

Treatment for this condition consists of combination therapy, the hallmark of which is supporting the arch to keep the ligament from overstretching. In addition, anti-inflammatory measures are undertaken to include oral medications, local injection therapy, plantar taping, ice massage, as well as posterior muscle group stretches. If necessary, we will recommend functional orthotics (custom rigid arch supports), which offer the best support possible to alleviate the strain on the ligament and allow for healing (see image 2 above) In rare instances, when orthotics do not alleviate symptoms, surgery may be recommended to "stretch" the ligament.

 

 

---

---

It is absolutely vital to wear orthotics throughout the entire weightbearing portion of your day, this in order to successfully treat the condition and prevent recurrence.

Functional orthotics are custom molded devices. As such, a higher fee is charged for this treatment. Usually HMO's will not cover this form of treatment, which in our opinion is the best conservative method for this condition. PPO insurance and indemnity may pay a portion of the orthotics, with the balance being the patient's responsibility. In some instances, two pair of orthotics may be recommended, this in order to accommodate both lace-up style casual wear, as well as women's dress shoes. A discount is usually offered for the second pair.

When conservative care, including functional orthotics, fail to relieve heel pain, surgery may be recommended. This usually consists of partial cuttinq of the plantar ligament. This procedure will result in a stretching of the plantar ligament, which relieves the tension and pain. py.