Heel Spur Treatment Guide
Heel Spur Information on Conservative Treatments
The following information is an educational aid and does not constitute the practice of medicine. If you have a medical problem, http://www.heel-spur-treatment.com recommends that you seek the help of your physician or other healthcare professional.
If you are suffering from heel pain you are not alone. In a recent poll conducted by a the American Podiatric Medical Association(APMA) last year, found that 55% of Americans missed a day of work because of foot problems.
Fortunately for these heel pain sufferers, customized shoe insoles have a 68% success rate of helping with this pain according to a study published in the Journal of the American Podiatric Medical Association (November/December 2001).
Heel Spur Treatment Guide Contents1. What is a Heel Spur?
2. How do we develop plantar fasciitis?
3. What are the forms of plantar fasciitis?
4. What are the most common types of treatment for plantar fasciitis?
5. What are the heel spur surgical options?
6. What is your best treatment option?
7. What stretches help reduce heel pain?
8. How can you prevent re-injuring the heel?
Heel spurs is the more common name for a condition that is medically
referred to as plantar fasciitis or heel spur syndrome. Plantar
fasciitis is a location oriented term that refers to the bottom of the
foot(i.e. plantar warts). Fascia is a tough, inelastic band.
'itis'is a term used to describe something that is
inflamed (i.e. tendonitis, bursitis).
Fascia tissue is located throughout the body, usually providing support to the musculoskeletal system, providing rigidity, much like guide wires support a cell phone tower. Together with ligaments and tendons, fascia allows our body system that allows us to be mobile. Plantar fascia (foot fascia) originates on the base of the heel and runs across the arch of the toes. The primary function of the plantar fascia is to support the arch of the foot.
Have you ever though about how many steps you take in a day?
Most likely this number is in the thousands. With each step, the load of the body weight to be applied to the arch causing the arch to drop. This drop in the arch makes the ball of the foot and the heal want to spread further apart. The fascia in the foot goes into tension to resist this force. If this tension in the fascia is greater than the fascia can handle, the fascia is damaged and the area will become inflamed.
The load applied to the foot is divided into two types:
- Intrinsic load
- Extrinsic load
The intrinsic load stems from the muscles contracting to move the foot. Much of the intrinsic load applied to the fascia results from the calf muscles. The plantar fascia is part of a larger structure termed the CT band ( CT is an acronym for Calf to Toes ). The main components of the CT band are the calf, Achilles tendon and plantar fascia. All these components are linked so that tension on any part of the CT band increase tension in the entire system. Of the 3 components of the CT band, the plantar fascia is the weakest link.
Extrinsic load refers to all the other loading factors in the plantar fascia other than the intrinsic load. Some of these factors are body weight, frequency of steps, duration of standing.
Plantar fasciitis is a form of repetitive stress injury. While supporting the load, the fascia creates tiny microscopic tears in the tissue. This is completely normal, In a healthy foot, the foot is able to repair itself at a greater rate than the damage it absorbs. As long as the amount of damage is lower than the body's ability to heal itself, the foot will remain healthy. Plantar fasciitis occurs when the sum total of damage is larger than the amount of healing the body can perform in a day. The foot is used so much in the course of the day that once the amount of damage exceeds the body's ability to repair itself, the pain will tend to persist.
To simplify this, the foot pain you feel when you get up in the morning exists because you caused more damage yesterday than your body could heal last night as your slept.
If you currently are suffering from heel pain, one of the first things you should try is to make sure to wear your shoes around the house in the evening and in the morning. The insole in your shoes will help to support the arch of your foot and may help the ligaments to heal on their own. If you walk around barefoot or with just socks on, your arch has to support all your weight by it's self.
- Primary plantar fasciitis
- Secondary plantar fasciitis
Primary plantar fasciitis, plantar fasciitis results from a mechanical overload of the plantar fascia by the sum of intrinsic and extrinsic loads.
Secondary plantar fasciitis is the result of direct trauma to the fascia and systemic diseases, like arthritis, that may effect the attachment of the fascia to the heel bone (calcaneus).
We've seen how a 'heel spur' is not actually a bone problem, it is still important to have x-rays of the affected area. Even though heel pain is primarily a result of soft tissue damage, there are several conditions that can also cause heel pain.
- Stress fractures
Treatment of plantar fasciitis must begin with determining if the condition is primary or secondary plantar fasciitis. Primary plantar fasciitis makes up at least 90% of all cases of planar fasciitis.
Treatment of Primary Plantar FasciitisThere are four main types of treatment options:
- Biomechanical methods
- Anti-inflammatory methods
- Extracorporeal Shockwave therapy
Fortunately for heel pain sufferers, the human body has an amazing ability to heal itself. In order for this to happen with plantar fasciitis, the amount of damage that is caused by loading throughout the day must be reduced so that the body can heal itself. Plantar fasciitis persists as long as the amount of damage incurred during the day exceeds the ability of the body to heal itself.
Biomechanical MethodsPlantar fasciitis is a mechanical condition. This is a fancy way of saying that plantar fasciitis results from forces exerted by the body as we walk. Mechanical conditions are often best treated with mechanical treatments.
An excellent example of a mechanical solution is to elevate the heel by wearing a 3/8 inch heal lift or wearing shoes with a higher heal or a wedged sole. Elevating the heel reduced the amount of tension on the CT band. It also changes the angle of the foot to the ground changing the way that the load is supported. This reduces the amount of damage to the plantar fascia during the day.
Stretching is another biomechanical method to help with heel pain is the stretch the calf muscle. Stretching the calf elongates the tissue in the CT band and reduces the amount of tension helping to re-balance the normal biomechanics of the foot and leg. This reduction is tension lowers the amount of damage created during normal walking activity.. Two great stretches are the Stair Stretch and our personal favorite the Wall Stretch. ( See the Section on Stretches for more explanations.) These stretches should be performed 6 times a day.
Other biomechanical methods include:
- Stretching splints
- Stretching slippers
- Heel cups
- Taping the arch ( see the section on taping the foot )
All these devices focus on changing the biomechanical properties of the CT band. While these devices may help provide very quick relief to the area, the key to rehabilitating plantar fasciitis is the address the entire CT band and not just the plantar fascia. To only focus on the plantar fascia is to only address the symptom versus correcting the problems within the CT band. It would be like taking aspirin to help deal with the pain of a broken bone but not mending the bone.
Stretches, heel lifts and rest, are often all that is needed for complete resolution of symptoms. That being said, arch supports can be used on a daily basis help support the arch and decrease the possibility of recurrence of plantar fasciitis.
Anti-inflammatory methods include steroid injections, oral anti-inflammatory medications such as aspirin, NSAID( Nonsteroidal Anti-Inflammatories) prescriptions, ultrasound, massage, topical medications and other methods to reduced inflammation.
The important thing to remember is that you are treating a problem that is caused by overuse or overloading. Anti-Inflammatories help us address the dull aching type that can progress throughout the day. They do not help with the sharp tearing pain (post dystatic pain )often experiences when you get out of bed.Anti-Inflammatories deal primarily with the symptoms of pain and not the actually problem that is causing the pain. It is important to combine biomechanical methods of care with anti-inflammatory treatments.
Extracorporeal Shock Wave therapy( ESW )This is a technique that has recently been developed to break the cycle of re-injury associated with plantar fasciitis. Shockwave therapy was originally developed to treat kidney stones non-invasively. Shockwave therapy revolutionized the Urology ( urinary system surgeons ) by giving surgeon the options of treating the kidney stones without:
- Invasive surgery No cutting
- Overnight hospital stays, before stone removal surgery require multiple days in the hospital
- Less damage to the kidney area
A company called HMT ( High Medical Technology ) developed the OssaTron. HealthTronics SSI (Nasdaq symbol: HTRN ) distributes and operates the OssaTron in the United States and Canada. The HealthTronics' OssaTron(r) was the first high-energy ESW device in the U.S. approved by the Food and Drug Administration (FDA). The OssaTron is the only device in the U.S. approved to treat two chronic orthopaedic conditions, chronic plantar fasciitis and chronic lateral epicondylitis, more commonly referred to as tennis elbow. HealthTronics currently operates approximately 60 OssaTrons throughout the country and the Company has performed approximately 15,000 procedures since receiving FDA approval for its first indication in early 2001.If you have been suffering from heel pain for months and it just isn't getting better, you should contact HealthTronics - Click Here
Shockwave therapy uses a acoustic energy wave that is focused at the area of pain. It is believed that the shock wave causes micro-trauma to the area. This micro-trauma stimulates an intense focused inflammatory response that promotes healing at the insertion point of the plantar fascia.
Shock wave therapy requires a high level of energy and can be painful. Most patients in the U.S. have the procedure performed in an outpatient setting with twilight sedation ( MAC sedation). The procedure takes about 15 minutes to perform. Patients are able to walk on the foot the same day of treatment. Complications have been minimal. Most doctors advise continued stretching an limited activity for approximately 4 weeks after surgery.
The long term success of Shock Wave therapy has yet to be seen, although short term success rates have success rates of 65% -95%. The best success rates seem to result from treatments with high-energy shock waves. The OssaTron is a high-energy treatment option. ( December 2003 )
Recently, the American College of Foot and Ankle Surgeons (ACFAS) and the American Podiatric Medical Association (APMA) have released a joint policy statement endorsing the use of extracorporeal shock waves (ESW) for the treatment of plantar fasciitis, more commonly known as heel spurs or heel pain syndrome. This policy statement acknowledges ESW as ``revolutionizing the treatment of chronic heel pain, much the same way the lithotripter did for kidney stones in 1984.''
Two articles published in Foot & Ankle International(r), a publication of the American Orthopaedic Foot & Ankle Society, support the efficacy of shock wave surgery with the OssaTron(r) to treat chronic plantar fasciitis. The articles, titled ``Symptom Duration of Plantar Fasciitis and the Effectiveness of Orthotripsy(r)'' and ``Effect of Extracorporeal Shock Waves on Calcaneal Bone Spurs,'' were published in the December 2003 edition of Foot & Ankle International, Volume 24, Number 12.
Surgical options should be the last resort as they have the greatest risk of complications. Plantar fasciitis surgery has come a long way in recent years, even though the basic technique remains the same. The basic idea of surgery is to manually release the fascia of the foot with the hope that the pain will be eliminated, medically termed plantar fasciotomies. Older techniques involved a large incision made in the foot and then removal of the calcium deposit ( bone spur ) or a removal of part of the heel. The technique has evolved to release the fascia because the bony heel spur does not seem to be the source of the pain but rather a side effect of the inflammation of the area.
Surgery has the risk of further complications dues to changes of the structural support of the foot. Possible complications include:
- Fallen arches
- Lateral Column Syndrome
- Nerve damage
More recently, Dr. Steve Barret, DPM of Spring, TX has developed a new endoscopic techniquem called Endoscopic Plantar Fasciotomy or EPF.
Tools developed by Dr. Barret allow the procedure to be performed with 2 small .25 inch incisions. Patients are often able to return to the feet in just a matter of days. Dr. Bartlett has greatly reduced the complications and possible disability of the older surgical treatments.
It is up to you and your doctor to determine the best option for alleviating your heel pain.
The first issue to consider is the amount of time that you have been experiencing pain?
Many cases of plantar fasciitis will be healed by the body itself. Use of bio-mechanical methods and anti-inflammatories may help. A good way to think of this is that these conservative options aid the body in healing itself. Unfortunately, they do not always work.
If you have been experiencing pain for more than 4 months of conservative care ( Biomechanical and anti-inflammatory methods ), you may be a good candidate for a more aggressive treatment option.
Extracorporeal Shockwave Lithotripsy is a great next step. The micro-trauma of the shockwave treatment is very successful in triggering the body fully heel itself. One of the greatest benefits of ESL is the risk of complications is minimal. The treatment is either successful or it is not. If you have been suffering from heel pain for months and it just isn't getting better, you should contact HealthTronics - Click Here
Surgery, either endoscopically or traditional methods, has many more risks than the above treatment methods. Approximately 90% of EPF cases go smoothly. The other 10% have complications that range in severity.
Regardless of how they are performed, Lateral Column Syndrome ( LCS ) is a common complication to plantar fasciotomies. LCS develops about 2-4 months after a plantar fasciotomy.
A theory of how LCS develops is that the pain in the foot goes away before the foot is completely healed. While the patient may not feel pain in their heel a month or 2 after surgery, the bio-mechanical changes to the foot are not complete until at least 4 to 6 months after surgery. A dull ache of the lateral (outside ) of the foot and the top of the arch may be early symptoms of LCS. If left untreated, this ache may develop into stress fractures in the dorsal and lateral areas of the foot.
LCS is manageable, however it should be discussed with your surgeon before surgery.
Treatment of Secondary Plantar Fasciitis
Secondary plantar fasciitis encompasses all conditions that are not a result of loading. Direct trauma and arthritis are both examples of Secondary Plantar Fasciitis.
Plantar fasciitis due to arthritis is a systemic disease. Focusing on the systemic disease is the best way of coping in this instance. The occasional cortisone shot may be of benefit.
Trauma to the foot generally comes in two types:
- Direct trauma
- Indirect trauma
Direct trauma may be a blunt trauma to the top of the arch, puncture or cut. Indirect trauma may result from swelling of the foot stemming from a fractured ankle. Care of the trauma should be the first course of action.
Trauma requires medical care. It may also include Rest, Ice, Elevation (RICE) immobilization and wound care.
There are many ways to stretch the calf muscles and tendons, the following stretches are what we have found to be the most effective.
This is a great stretch to do. Begin by finding a step, curb and something you can hold onto to maintain your balance. Remember to slowly ease into the stretch. Bouncing may cause further trauma to the area.
While wearing shoes, locate a doorway.
- Reach through the door way so that you can balance yourself.
- Position one of your feet so that:
- The ball of the foot is firmly against the wall.
- The heel of the foot is firmly pressed into the ground.
- Begin to slowly apply pressure by pulling your body towards the
wall, making your lower leg more perpendicular to the floor.
- Repeat with the other foot.
To avoid re-injuring the fascia and causing further pain, the APMA has the following recommendations:
- Always consult a foot specialist before starting a new exercise program
- Allow your body to adapt to the exercise program by starting slowly. It takes time for the body to adapt to the additional stress.
- Purchase and maintain good shoes and replace them regularly. Investing a little more money in good shoes will pay dividends in pain-free living.
- Remember to stretch your feet and Achilles tendon before and after exercise.
- Always try to exercise on an even surface. Uneven surfaces can but strange stressed on the foot and can result in pain.
- Avoid walking barefoot on hard surfaces. Without your shoes, you fascia has to support your entire body weight.
- If it hurts, STOP. Don't try to bear through the pain.