Heel Pain: What is it, What can you do?

Not a week passes by that while I am walking through the gym, I notice someone passing by who cannot put one of his or her heels on the floor. Some are women, some men, some thin and some heavy. As long as you walk, you are candidate for heel pain.

Every year, millions of Americans suffer from heel pain. By far, the majority of the cases of heel pain are caused by a condition known as plantar fasciitis (pronounced: fas-HEE-I-tis). This condition refers to the inflammation of the connective tissue that runs through the bottom of the foot from the heel bone to the front of the foot. This tissue is known as the plantar fascia. The fascia is most closely related to a tendon in appearance and texture, however, unlike a tendon there is no muscle attached to it. Due to the nature of this tissue, it is not very elastic and will get injured and begin to tear when exposed to excessive pressure. There are some factors that can make developing plantar fasciitis and heel pain more likely:

· Aging. As we age, tissue breakdown becomes more prevalent. Accordingly, aging contributes to likelihood of damage to the plantar fascia.

• Poor shoe gear. Shoes that have little or no support tend to place greater strain on the fascia.
• Sports. Activity such as high impact aerobics, running and dancing can put a lot of pressure on the heel thereby causing pain.
• Poor biomechanics. Persons with high arches or flat feet are more prone to get heel pain. People with flat feet apply a greater stretching force on the fascia. When they walk, they have a greater tendency to damage the tissue by over-stretching. People with high arches have very tight fascia. This results in poor absorption of shock and allows the fascia to become injured from strain.
• Weight. There are many serious problems associated with being overweight. One of these problems is a strenuous challenge to the muscles, connective tissues and skeleton. In the heel, carrying extra weight makes the injuries that occur with poor biomechanics happen more often as well as more quickly. The excess weight also causes breakdown of the protective fat pad under the heel bone, which can result in direct injury to the heel bone and the fascia.
• Occupation. People who have to stand at work for long hours on hard surfaces are also subject to heel injury.

There are usually classic symptoms associated with plantar fasciitis. Here is a list of what you might feel if you have this condition:

• Sharp stabbing pain on the inside part of the bottom of the heel.
• The pain is usually worst first thing in the morning or upon getting up after sitting for an extended period of time.
• The pain may decrease after getting up, but the longer you are on your feet, the more the heel hurts.
• The pain may diminish during exercise, but will increase soon after.

If you have this kind of heel pain, you are not alone. As I mentioned before, millions of people suffer from heel pain every year. However, if the pain doesn’t go away in a few days don’t ignore it. Although, most cases of heel pain are plantar fasciitis there is a possibility that it could be something else and even something more serious. Some of the other conditions that cause heel pain are:

• A stress fracture of the heel bone.
• A bone cyst or tumor in the heel bone.
• A nerve entrapment behind the ankle, called Tarsal Tunnel syndrome.
• Certain types of arthritis.
• A partial or complete tear of the fascia.

Now that you know what it is, what can be a contributing cause, what it feels like and what else it might be, what can you do to help control the symptoms of plantar fasciitis?

• First and foremost, is stretching. By stretching the back of the lower leg, you will relieve the tension on the heel and subsequently relieve the stress on the plantar fascia. The most important stretches are the typical runners wall stretch. These exercises should be done throughout the day; one set per hour is ideal. Watch my YouTube video to see the stretches demonstrated. http://YouTube.com/watch?v=_sDrvbd-Ppc
• Night splints are devices that are worn to bed. They hold the foot and ankle in a position to prevent contracting of the muscle and tendon that you have been stretching all day.
• Ice massage done one or two times a day for about 10 minutes. This can be done while sitting in a chair and rolling your arch and heel on a small bottle of frozen water.

The next phase of therapy consist of oral or inject able anti-inflammatory drugs. A physical therapy regimen may be utilized to reduce the stress and strain on the fascia as well as reduce the internal swelling. At this time, custom orthotics can be fashioned to relieve the pain from plantar fasciitis. Orthotics and continued stretching are the best insurance against having a recurrence of the heel pain.

After these treatments more than 90% of patients with heel pain will have minimal or no symptoms. If you are suffering from heel pain, stretch, ice, wear good supportive shoes, diet and see your podiatrist for a complete evaluation.

What about the 10% of those who are not pain free?

See my next article on the treatment of resistant heel pain. In this article I will review PRP (Platelet Rich Plasma) injections, ESWT (Extracorporeal Shockwave Therapy), and surgery for heel pain.

Healing yourself with Protein Rich Plasma

Platelet rich plasma (PRP) therapy is a cutting-edge non-surgical technique that is now available for use as an in-office procedure. Years ago, it was thought that platelets functioned solely to form blood clots — or, more specifically, to bind to each other at the sight of bleeding in order to form a “plug” to stop the flow of blood. Recent research has shown, however, that the platelet has a far greater role in the healing process than initially thought. When platelets aggregate at the sight of an injury, they not only form the plug to stem the bleeding but they also release growth factors. These growth factors, also known as cytokines, aid in the healing of injured tissues.

PRP Therapy: The Process

PRP therapy requires only a small amount of normal blood from the patient (approximately 20 cc’s). This blood sample is placed into a centrifuge in the office and is spun for approximately fifteen minutes. The final product is a highly concentrated platelet rich gel, which, when applied to injured tissue, accelerates the normal healing process.

On the day of the treatment, the patient is seated in the exam chair and blood is taken from his or her arm. Once the PRP gel is ready for implantation, the area being treated is injected with local anesthesia after which there is no further discomfort from the procedure.

To insure the accuracy of the placement of the platelet rich gel a diagnostic ultrasound is used. Then a needle attached to a syringe containing the gel is guided by the ultrasound into the areas of injury. After the procedure, a simple Band-Aid is applied. Because there is no surgical incision involved there is little or no post procedural pain.

The Science

When the PRP gel is applied to the area of injury, the platelets are activated to produce proteins capable of stimulating cellular growth, proliferation and cellular differentiation called growth factors. By concentrating the number of platelets found in normal blood by 10 times, the concentration of growth factors in the area is equally enhanced. This is significant in terms of the healing process because growth factors are responsible for attracting stem cells that will eventually become new tendon, bone or fascia.
The procedure is very safe. Since the blood is drawn and processed immediately in the same facility there is no chance of contamination or blood from another patient. Also since the injection consist of blood from the same patient begin treated there is no chance of allergy or drug reactions. Additionally, platelets have a natural antibiotic quality so there is very little chance of infection.

Use

In my practice, by far the most common ailment treated with PRP is the painful heel condition known as plantar fasciitis. However, I have also successfully treated tendonitis, partial tendon ruptures and inflammatory bone conditions.

PRP versus Cortisone Injections

When PRP is compared to cortisone injections for inflammatory conditions there are many striking differences. Cortisone injections result in immediate pain relief. PRP injections do not act as quickly. PRP procedures take longer to deliver results because the growth factors take time to grow the new tissue. However, the platelets release the growth factors that attract the stem cells and then produce repaired “new” tissue. The cortisone reduces the inflammation immediately but actually causes tissue weakening and damage. So the choice between cortisone and PRP comes down to fast relieve with potential tissue damage or actual new and repaired tissue that takes longer to relieve pain.
This new innovative and cutting-edge technique is just the beginning of the new branch of science known as “orthobiologics”. The day is fast approaching when medical science will be able to create new parts to cure the ailments and injuries that plague our bodies. “Protein Rich Plasma” is one of the modalities that are currently available to help the body accelerate the healing process and create new, repaired, healthy tissue.

The Case of the Elusive Glass Fragment

For the past 2 weeks, you have had a sharp pinpoint pain in your heel every time you take a step. You decide to see your podiatrist, who suggests that you take an X-ray to make sure there are no spurs, cyst or breaks in the bone. The X-ray is shown to you, and there are no sign of abnormality in the bone. Your podiatrist then suggests exploring the heel with diagnostic ultrasound.

An ultrasound may at first seem like an unusual imaging modality to diagnose the source of foot pain, especially since most people associate ultrasound imaging with pregnancy. Surprisingly, ultrasonography is a quick and inexpensive way to evaluate pathologies of the foot. In this case noted above, the ultrasound showed a concentrated bright spot in the heel with a tail of light waves behind the spot, which indicated a foreign body in the foot. Unlike ultrasound, X-rays can only pick up signals from metal and bone, which have denser properties compared to glass and soft tissue structures.

Science of the Ultrasound:

Ultrasound uses high frequency sound waves that are emitted from a probe that is applied to the skin. The sound waves painlessly penetrate the skin and encounter bones, ligaments and tendons. Each tissue type is made of different components, when the waves are reflected back to the probe they appear characteristic of that particular structure. The probe is attached to a computer that compiles the various sound waves and forms an image on a screen. Tissues that contain more water such as muscle will absorb the ultrasound wave and will send little or no waves back to the probe. These tissues that absorb the waves will appear on the screen as dark areas. Conversely bone, which contains less water, will reflect all of the waves back to the probe and therefore will appear on the screen as a white image. Using this gradient of relative amounts of reflected waves and a firm knowledge of the normal anatomy a trained podiatrist will be able to determine the difference between normal and damaged or injured tissues in your foot.

Other Pathology Visualized by Ultrasound:

1. Ganglions

2. Neuromas

3. Foreign Bodies (like glass or metal)

4. Achilles Tendon Rupture

5. Tendon Abnormalities

6. Rupture of the Ankle Ligaments (Sprains)

7. Fascia tears and inflammation (Heel pain)

8. Bursitis

Advantages of Ultrasound:

1. Uses no radiation like X-rays or Cat Scans

2. Can perform live active or passive range of motion

3. Cost effective, especially compared to MRI

4. Conveniently used in an office setting

Why should I have a skin biopsy?

Skin cancer. How do you know if you have it? Ever wonder about that spot on your foot? Is it new? Has it changed? Does it bleed? Is it darker then it was in the past?

Growths (lesions) or discolorations of the skin occur all over the body, including the feet. So, it is not surprising when your podiatrist requests that you should have a biopsy to further determine the exact nature of the lesion on your foot. Often, more serious life-threatening skin conditions that appear on the feet are assumed to be warts, calluses or blisters. Unless these skin lesions are biopsied and sent to a skin pathologist for examination under a microscope, there is a good chance that the true diagnosis will be missed. The biopsy will determine the exact nature and true diagnosis of the skin problem, and will find if the lesion is malignant or benign.

There are several types of skin biopsies that can be performed by your podiatrist in the office. They are called: Punch, Shave and Excisional biopsies. The method performed depends on the location of the problem area and the type of skin lesion that is being investigated. Most of the time, the biopsy is done to remove a small portion of the skin in order to send a specimen to the lab for special staining and subsequent examination under the microscope.

Things to expect when you have a skin biopsy:

Most skin biopsies are performed in the office. After the injection of local anesthetic, the procedure itself should not be painful. Once the area is numbed by the anesthesia the skin is cleansed to avoid infection. Next, the doctor will use a surgical instrument to remove all or part of the skin lesion. A blade is used for Shave or Excisional biopsies and a cylindrical cookie-cutter type of instrument is used for the Punch biopsy. After the skin sample is taken, an anti-bleeding solution is applied. In rare occasions, one or two stitches may be needed to close the wound. The doctor then will apply a bandage over the wound.

The bandage is left in place until the next day when routine wound care can be started at home. There is very little post-procedure pain from these biopsies and patients may have to take Tylenol when the anesthesia wears off.

Now it is about two weeks since you had the biopsy and it is time to return to the doctor’s office for a wound check and, most importantly, find out the result of your biopsy. Most often, the final diagnosis from the biopsy taken in the office will take around seven to ten days to get back to the doctor. The doctor will go over your results from the report that he received from the lab and review the treatment for your condition. I suggest that all patients take a copy of the lab report for their personal records. Now you have your answer, hope the news was good.

Other reasons for having a biopsy:

Have you had redness and itching on your feet? Do you have coin size patches on your feet? Do you have skin lesions with small dark spots? Have you used over the counter fungal creams and not seen improvement? Do you have an area on your foot that is drier, scalier, thicker or darker than your normal skin?

• To determine the cause of the skin problem. Biopsy can let the doctor know if the skin problem is being caused by an infection, such as fungus, verses an inflammatory condition like dermatitis. Also referring to the case above, to determine if the condition is a cancerous verses a benign growth.
• To accurately form the best course of treatment for the skin condition. If the result of the test shows there are no fungal elements, then anti-fungal agents would be useless in treating this condition. Also, if the result shows that the skin problem is from a fungus, using anti-bacterial such as polysorin or anti-inflammatory agents like steroid creams would be useless The result of the study may also suggest that the entire lesion be removed because this condition may have a chance of turning into a cancerous condition in the future.
• Biopsies can determine if the hard strange skin on your foot is a callus or a plantar wart. Knowing this can help appropriately treat the condition.