Heel Pain Season: What’s Your Strategy?

I do not know if this is the case everywhere in the country, but in Chicagoland, late spring is heel pain season. People have been cooped up in their homes waiting for the seemingly endless winter to break and when it does, people rush to get outdoors and start walking, exercising, playing golf, etc. They have been sitting around all winter and the onset of heel pain often accompanies this sudden return to activity.

It is not like heel pain is absent the rest of the year but there is a huge influx of patients suffering with heel pain this time of year. As heel pain is the #1 complaint of patients entering the office of podiatrists/foot and ankle specialists nationwide, it is important to have an evidence-based strategy for treatment and success. Many have studied and published some of the different treatments for heel pain. However, no studies have looked at a comprehensive evaluation of treatments from beginning to end of the heel pain continuum.

For years, we have evaluated the different treatment alternatives for heel pain and looked at what treatments were consistently providing the best outcomes in the most cost-effective ways. Through these processes and discussions with the Foot & Ankle Business Innovations Mastermind group, we have standardized and institutionalized our treatment pathways for heel pain and are able to tell patients what the timeframe for recovery and success will be with great predictability. 

For a patient presenting with heel pain that is clearly plantar fasciitis and he or she has not had previous treatments, our initial treatment consists of shoe gear modification. Specifically, we use higher heel shoes or running shoes to offload the heel, reduce the pull on the calf/Achilles and relax the windlass mechanism to take stress off the fascia. 

What about Birkenstocks? That is a common question I get from patients.  Yuck! Not only are they ugly but their low/negative heel is terrible for plantar fasciitis. There are much better sandal solutions such as Vionic and many others that have a heel and arch support.

We recommend a high quality over-the counter arch support, not some cheap pharmacy alternative. Several studies have shown that OTC arch supports are as effective for early-stage heel pain as orthotics and much more cost-effective.

What about taping? There is no doubt that taping can help but I have found that patients do not really like taping and prefer the OTC arch supports, which last longer.

We send patients to physical therapy or teach them stretching exercises. In regard to physical therapy, we want them to be doing things such as stretching, strengthening and mobilization, not unstudied and expensive activities such as ultrasound and iontophoresis. We emphasize that patients should stretch many times a day to have an effect on their equinus, which is so frequently a component of heel pain. Ordering physical therapy-related modalities such as the Graston Technique or Astym have helped.

If the patient’s morning pain is 7 to 8/10 on the Visual Analogue Scale, a night brace or “rest brace,” as we term it, may be appropriate. Studies have shown that night bracing has a positive effect on morning heel pain.¹ I have personally found that some people do not tolerate the brace so we suggest they wear it in times of inactivity such as watching TV or reading to get accustomed to it, and many people can then transition into it.

The use of non-steroidal anti-inflammatory drugs (NSAIDs) and topical medication can help reduce pain and swelling, and break the pain cycle that is often a part of the heel pain problem. Additionally, we advise patients to submerge their heel in ice water for 10 minutes once or twice a day.

We ask patients to reduce their weightbearing exercise and look for things such as biking, swimming and weightlifting as temporary exercise options.

We ask patients to work with this regimen for three to four weeks and typically see 50 percent improvement in over 80 percent of patients.

Should You Perform Cortisone Injections?

Wait, I didn’t perform a cortisone injection? No, I did not. It has been our philosophy that cortisone is not appropriate at the initial visit if the patient has not already failed other attempted treatments. While cortisone may provide immediate relief in many situations, it does weaken tissue. If there is damaged tissue that is weakened and now pain-free, worse problems can occur.

Furthermore, there are many things that truly help the mechanical cause of heel pain (see above) and if patients are pain-free, they always neglect to do those things. Once the cortisone wears off, the pain is back … and often worse. I have always been a less frequent user of cortisone than the average physician. I feel that if I can get patients better without cortisone, I have accomplished something positive for them. Cortisone is appropriate at the right time but rarely do I consider it on a first visit.

If patients have improved by the aforementioned 50 percent or more, we will typically continue with the initial regimen and may consider a more permanent orthotic device. One can anticipate that people will continue to improve at a rate of 50 percent a month when treatment is working.

If patients have not improved by 50 percent after a month of initial treatment, we will then move into the next phase of treatment. If clinical indications are still pointing to a diagnosis of plantar fasciitis, we will consider a cortisone injection.  When performing a cortisone injection, we utilize a combination of 1-1.5 cc of 0.5% bupivacaine plain, 0.5 cc of dexamethasone, 0.5 cc of Kenalog (Bristol-Myers Squibb) in a 3 cc syringe with a 30-gauge needle. With this technique and ultrasound guidance, our patients consistently comment on how unexpectedly comfortable the injection was. Since peer-reviewed studies showing improved outcomes with injections under ultrasound guidance have been published, we have been employing that technique and anecdotally the results are superior.^2,3

At this juncture, we will also recommend custom orthotics. I have been a functional orthotic device wearer for 46 years. However, it has been my experience over the last 15 years that patients with heel pain respond in a superior manner to functional/accommodative hybrid devices that incorporate cork, ethylene vinyl acetate (EVA) and high density foams than typical functional devices. I have consistently moved people from excellent functional devices into these hybrid devices with patients reporting improved comfort.

In the unusual situation when a patient presents with pain levels that are extreme, using non-weightbearing walking boots, a Medrol dose pack (if one has ruled out a fracture) and magnetic resonance imaging (MRI) may be appropriate.

In Conclusion

Heel pain is the most common problem we all see on a daily basis. While we have been successful with our protocols over many years and tens of thousands of patients, your regimen may be different. As long as you base it on evidence and outcomes, there are many ways to approach this common problem. Having a standardized approach will help improve outcomes for your patients, improve efficiencies in your practice and provide a better overall experience for all involved.

In next month’s DPM Blog: What happens when your heel pain regimen fails? 

References

1. Berlet GC, Anderson RB, Davis H, Kiebzak GM. A prospective trial of night splinting in the treatment of recalcitrant plantar fasciitis: the Ankle Dorsiflexion Dynasplint. Orthopedics. 2002;25(11):1273-5.

2. Tsai WC, Hsu CC, Chen CP, Chen MJ, Yu TY, Chen YJ. Plantar fasciitis treated with local steroid injection: comparison between sonographic and palpation guidance. J Clin Ultrasound. 2006;34(1):12-6.

3. Li Z, Xia C, Yu A, Qi B. Ultrasound versus palpation-guided injection of corticosteroid for plantar fasciitis: a meta-analysis. PLoS One. 2014 Mar 21;9(3)