A Guide To Conservative Care For Heel Pain

Over the years, podiatrists have become the primary health care providers for all forefoot conditions and most rearfoot conditions. With greater public awareness and increased referrals from primary care doctors, heel pain pathology is perhaps the most common foot pathology we treat in our offices. As a result, many new devices and surgical techniques have emerged in recent years to help improve our outcomes.

Unfortunately, some of these newer methods and techniques are not always necessary and may not demonstrate the same outcomes that some of the research states.

It is critical to listen to lectures and read articles about new methods of conservative and surgical management with respect to heel pain. However, be aware that many of the speakers or authors who are presenting the research are often affiliated with the companies they are speaking about.

When a patient complains of heel pain, it is important to explain to him or her that there is no one magic modality that will resolve the heel pain. It will require a combination of different types of treatment and changes in habits to help resolve the patient’s pain. We always find it interesting when some doctors say that 30 to 40 percent of their patients with heel pain may require surgical care. In our experience, patients who have heel pain syndrome with fasciitis can usually resolve their symptoms in more than 90 percent of cases with conservative management.

Accordingly, let us take a closer look at the realities of conservative care for heel pain and provide a stepwise treatment plan to help improve your outcomes.

Assessing The Possible Etiologies Of Heel Pain
Most heel pain is biomechanical in nature and may develop with increased weight, trauma or overuse with poor shoe gear. The most challenging type of heel pain occurs when there is associated nerve pain either from tarsal tunnel syndrome or medial or infracalcaneal neuritis. Another type of heel pain that may come and go is systemic-related pain (i.e. rheumatoid arthritis, seronegative arthritis or fibromyalgia). When a patient has arthritis-related heel pain, our treatment plan would only include conservative management.

Until there are randomized, double-blind studies demonstrating the safety of extracorporeal shockwave therapy (ESWT), Topaz (Arthrocare) or cryosurgery in these patients, podiatrists should be very cautious. Surgeons rarely perform open or endoscopic methods of surgery on these patients as these procedures may aggravate the patients’ symptoms.

Current Insights On Heel Pain Pathology
Most specialists now believe that plantar heel pain syndrome is caused by acute and chronic inflammation of the fascia. This is beginning to influence our treatment plan in that some patients with acute inflammation, vascular congestion or a possible stress fracture may require Cam Walker immobilization for two to four weeks prior to beginning the early steps in our treatment protocol.

If inflammation is the etiologic factor, then clinical signs such as pain, heat, redness, swelling and histologic evidence of leukocyte accumulation should be present in the acutely inflamed patient.1 In some patients with acute, severe heel pain, there may be a stress fracture, vascular congestion or periostitis of the calcaneus. There have been several studies over the years describing this possibility but it is difficult to determine for certain even with the benefits of nuclear imaging, an MRI or CT scan. The majority of patients will have chronic “fasciitis” and histologically, there may be an increased infiltration of macrophages, lymphocytes, plasma cells, tissue destruction and evidence of repair. However, many chronic patients with heel pain syndrome seem to have a degenerative process without true inflammation of the fascia. Lemont documented this in a study in 2003.1

Over the past few years, new considerations that seem to influence one’s treatment plan are the hypovascularity of the fascia and the thickness of the fascia. Some specialists use an advanced type of ultrasound with a color Doppler to visualize this. For most practitioners, this is not practical and is an unnecessary expense to the patient and the insurance company. When using ultrasound, Dopplers or an MRI for heel pain management, the clinician should assess whether these imaging modalities will affect his or her treatment plan. If it is not going to influence their care, then it is not necessary. One’s clinical exam and plain X-rays should provide enough information to begin forming a treatment protocol. However, the hypovascularity of the fascia may be the primary reason some patients do not respond to conservative management.

What You Should Consider As First-Line Treatment Options
In regard to the initial visit, one should consider appropriate shoes, OTC orthotics, stretching exercises, antiinflammatory medications, ice, having patients avoid walking barefoot, weight loss and/or a topical herbal gel.

Advise the patient to wear his or her new shoes, and OTC orthotics (i.e. Superfeet or Powerstep) even when he or she is in the house. Ice massage can be helpful with a frozen bag of vegetables. The patient may also use a frozen water bottle and stand over it while rolling the heel on it.

Topical herbal gels such as Biofreeze and Cryoderm can be soothing. If patients use these modalities twice a day, they can have an antiinflammatory effect. For most patients, these products will provide improvement of heel pain for only an hour. Biofreeze includes Ilex as the main ingredient whereas Cryoderm includes MSM, Arnica, Boswella and Ilex. The Cryoderm product penetrates more deeply.

What About Corticosteroid Injections And Tape Strapping?
Corticosteroid injections often include lidocaine or marcaine mixed with 0.5 cc of trimacinolone acetate. These injections alleviate heel pain by modifying the vascular inflammatory response, restricting leukocyte and macrophage accumulation at the site of injury, preventing vasoactive kinin release, inhibiting destructive enzyme release and decreasing prostaglandin formation.2

In a recent study, researchers recently compared corticosteroid injections with a new type of intralesional autologous blood injection.3 This was a prospective randomized controlled study on 61 patients. This type of injection theoretically should be helpful for patients who have hypovascularity of the fascia. However, the study revealed that corticosteroid injections were more beneficial in terms of the speed of response and the extent of improvement.

The tape strapping helps to immobilize the foot during the first few hours. Unfortunately, the taping loosens up about 50 percent after an hour once it is applied. It is helpful to teach your patients to re-tape themselves between office visits. This will help facilitate the maximal outcome from the injection.

What Are The Verdicts On Night Splints And Physical Therapy?
A night splint is often helpful for patients who have post-static pain. It is usually very beneficial if the patient is able to tolerate it well.

For the first few nights, ask the patient to use the night splint when watching TV or reading. After the patient gets used to it, he or she will be able to sleep with it more easily. Every hour helps. Encourage the patient to use it with a thick sock and advise him or her it is not necessary to position the foot more acutely than 90 degrees to the leg.

Physical therapy can be very beneficial for heel pain syndrome. These modalities usually include phonophoresis, electrical stimulation, ice, stretching and deep tissue massage. However, be specific with your prescription for heel pain. It is common that physical therapists will try to strengthen the foot musculature from the initial visit and this often aggravates the symptoms.

Advise the patient and physical therapist to avoid strengthening exercises until the patient has minimal pain.

One can perform phonophoresis with dexamethasone or lidex mixed into the gel. We used to have the physical therapist get this compounded for us but it simply costs too much with respect to current reimbursement from insurance carriers. A good alternative has been to mix Cryoderm with the gel or use a different herbal cream called Traumeel (Heel USA). These both work well for plantar fasciitis when one uses them via phonophoresis.

Custom Functional Foot Orthotics: Can They Have An Impact?
Orthotic labs continue to improve the technology for making these devices. The best labs use computer assisted devices (CAD-CAM) to help scan a three-dimensional image of your cast. The podiatrist can then prescribe the device with a medial skive technique and/or inversion to help better support the subtalar and talonavicular joints respectfully.

In the upcoming year, we will be able to take a three-dimensional scan of the foot with a computerized scanner in our offices and send the information directly to the lab with our laptops. These scanners are being experimented with at this time.

When casting a patient who has plantar fasciitis, it is vital to plantarflex the medial column of the foot to help correct for supinatus or flexible forefoot valgus. This will help to create an orthotic that plantarflexes the medial column better and relaxes the windlass mechanism, which puts stress on the fascia in gait. Orthotics may be difficult to use when the patient has acute inflammation. Sometimes, one may use a softer device (i.e. Spenco Polysorb Crosstrainer) initially. Once there is improvement in the acute phase, a more supportive device will be better tolerated and more effective in the long term.

When Should You Consider Cast Immobilization?
Clinicians may pursue cast immobilization in conjunction with giving a final corticosteroid injection. You may have patients use a below knee walking cast or Cam Walker for four to eight weeks to help alleviate pain and break up the pain cycle.

What You Should Know About ESWT
This is a non-surgical treatment that one would perform in the office with the patient under local anesthesia. We have had mixed results with this technique. It has been confusing to all of us with so many different types of ESWT companies. However, we have had some terrific success stories in athletes and believe clinicians should use this type of treatment prior to an open incision, Topaz, cryosurgery or an endoscopic procedure, which requires treatment in a hospital or surgery center.

Extracorporeal shockwave therapy seems to create controlled local tissue injury that causes neovascularization and increases the amount of tissue growth factors within the locally injured structures. It may also affect pain perception by a chemical alteration of pain receptor neurotransmitters.4

We have found the lower energy shockwave systems are more gentle and have fewer complications. We typically use a gel heel lift for the first week with tennis shoes and minimize patient walking for the first two weeks.

Until insurance companies start covering this treatment technique, its use will continue to be limited. However, in our experience, it seems to help reduce the thickness of the fascia as seen on ultrasound and must be improving the vascularity of the injured fascia.

A Few Thoughts On Relatively New Modalities
In regard to the emergence of Topaz coblation radiofrequency and cryosurgery techniques, we need to wait and see more research about these treatments. They are good alternatives to an open surgical fasciotomy or endoscopic treatment because they do not transect the fascia. However, most reports have been from people affiliated with the companies or who have financial incentives to promote the products.

Allen and Fallat recently revealed their results on 59 cryosurgery procedures.5 It will be interesting to see if others can reproduce their successful results. We are still waiting to see a scientific outcomes study on Topaz. However, Takahashi published an intial report this year.6

When Surgical Repair May Be Necessary
If a patient has nerve involvement, than an open procedure may be necessary. This may require a recovery period of 10 to 14 weeks. In regard to endoscopic procedures, the recovery period in our experience is eight to 10 weeks.

Some critics of the endoscopic procedure have expressed concerns about post-op lateral column pain. This is a very rare occurrence since we have changed our post-op management from immediate weightbearing in shoes to partial weightbearing in a below knee cast for three weeks. Bazaz and Ferkel reported excellent results with an endoscopic plantar fascia release when they were more conservative with the initial post-op care.7

Final Notes
Conservative management of heel pain should be the emphasis of every foot specialist treating this pathology. A staged or stepwise approach will help to achieve better outcomes. This also continues to emphasize to the entire medical community that heel pain should be primarily treated by podiatrists as we produce more rapid results by having an organized treatment plan.

Be cautious with some of the new treatments for recalcitrant heel pain and only believe half of what you hear until there are more scientific studies on these methods.
 

References:

1. Lemont H, Ammiratti KM, Usen N. Plantar fasciitis: a degenerative process (fasciosis) without inflammation. JAPMA 93(3): 234-237, 2003.
2. Noerdlinger MA, Fadale PD. The role of injectable corticosteroids in orthopedics. Orthopedics 24(4): 400-405, 2001.
3. Lee TG, Ahmad TS. Intralesional autologous blood injection compared to corticosteroid injection for treatment of chronic plantar fasciitis: a prospective, randomized controlled trial. Foot & Ankle Intl 28:984-989, 2007.
4. Malay DS, Pressman MM, Assili A, Kline JT, York S, Buren B, Heyman ER, Borowsky P, Lemay C. Extracorporeal shockwave therapy versus placebo for the treatment of chronic proximal plantar fasciitis: results of a randomized, placebo-controlled, double-blinded multicenter intervention trial. JFAS 45(4): 196-210, 2006.
5. Allen BH, Fallat LM, Schwartz S. Cryosurgery: an innovative technique for the treatment of plantar fasciitis. JFAS 46(2):75-79, 2007.
6. Takahashi N, Tasto JP, et al. Pain relief through an antinociceptive effect after radiofrequency application. Am J Sports Med 35(5):805-10, 2007.
7. Bazaz R, Ferkel RD. Results of endoscopic plantar fascia release. Foot & Ankle Intl 28:549-555, 2007.