February 18, 2014
There are two types of heel pain that send patients to the orthopedist: back of the heel pain (Achilles Tendinitis or AT) and bottom of the heel pain (Plantar Fasciitis or PF). The symptoms in both conditions are similar: first step, or start up, pain after getting out of bed in the morning and pain after getting up from prolonged sitting. After a few steps, the pain lessens, but with increased activity through the day it worsens. Usually only one heel is involved, and there is no pain at rest.
The cause is similar in both syndromes. The Achilles tendon (heel cord) attaches the lower calf muscle to the back of the heel bone. Pain in the back of the heel (Achilles Tendinitis) is due to a breakdown of this attachment.The Plantar Fascia is a ligament which attaches the toes to the bottom of the heel bone and supports the arch. Pain at the bottom of the heel (Plantar Fasciitis) is due to a breakdown in this attachment.
The culprit, in many cases, is an over tight Achilles tendon which places extra stresses on attachments to the heel bone. Over time the attachment frays and the body`s effort to repair it stalls.
- A tight Achilles tendon places direct stress on its own attachment at the back of the heel bone which can cause Achilles Tendinitis.
- A tight Achilles tendon also can cause Plantar Fasciitis: if the Achilles is tight the foot resists bending upwards during normal walking and running, thus placing additional stress on the plantar fascia as it tries to compensate for the tight Achilles by flexing more than usual. This stress is concentrated at its attachment on the bottom of the heel.
It is the resultant non healing state of the tendon or the fascia (both termed “tendinopathies”) that causes the chronic heel pain. (Interestingly, these two conditions do not coexist at the same time). Usually the patient endures months of suffering, hoping the problem will resolve, before seeking medical help.
Our goal in treatment is to try and “jump start” the healing process. We use physical therapy, anti-inflammatory medication, shoe inserts, daily heel cord and plantar fascia stretching exercises, and night splints that stretch these soft tissues during sleep. High impact sports are curtailed and behaviors detrimental to healing (smoking, poor nutrition, unsupportive foot wear, excess weight) are addressed.
Steroid injections into the heel cord and plantar fascia are used sparingly, if at all. They delay local healing and may weaken the tissues, predisposing them to rupture. Injections of Platelet Rich Plasma (PRP), a spun down concentrate of a person’s own blood, have been used to treat these conditions. Though considered experimental and somewhat controversial, PRP injections have been shown in some cases to accelerate healing.
Occasionally surgery is used, but more with Achilles Tendinitis than Plantar Fasciitis. (Making an incision in the skin over the back of the heel is much better tolerated than going through the very thick skin and fat pad on the bottom of the heel). Sometimes all it takes to restart healing is to remove surgically the non-healing tissues from the Achilles` or Plantar Fascia`s bony attachments. In other cases, the Achilles tendon may need to be detached, cleaned off, and reattached into a new freshened bed of bleeding bone. This is not done with the plantar fascia for reasons stated above and because the results are less predictable.
Once the AT or PF has resolved, whether through conservative or surgical means, it is important for the patient to be on a maintenance program to prevent recurrence. A one hour program of stretching and brisk walking at least three times a week is highly recommended. Stretching is particularly important because healing tissue(scar) tends to shorten and tighten with time, rendering it more vulnerable to re-tearing.
Other causes of heel pain include stress fractures, pinched nerves, infections, arthritis, and tumors. Although these conditions are always kept in mind when assessing the cause of a patient`s chronic heel pain, they are uncommon. When the diagnosis is AT or PF, early treatment ensures the best possible outcome from these two common, but debilitating conditions that interfere greatly with an active lifestyle, so important to general health and wellness.