Heel pain not caused by heel spurs

Joe went to his doctor after suffering for over a year. His pain was not debilitating (not yet anyway), but he simply didn’t want to do much, at least anything active, since it meant more discomfort. Joe wasn’t particularly fond of the sensations coming from the bottom of his heel, which could be aching and other times sharp. Getting out of bed in the morning was an adventure, entailing him tiptoeing around the house for a while until the pain subsided. And it was getting worse and not better.

X-rays of Joe’s foot revealed a mean-looking bone spur coming off his heel right in the area of pain, so it must be the cause, mustn’t it? He was concerned surgery might be needed to remove this bony projection. A cortisone injection gave him great relief: perhaps it dissolved the spur? But then his heel pain began sneaking back after a few months and ultimately returned to full strength.

Anyone with eyesight and a layman’s knowledge of x-rays could pick out Joe’s heel spur on a side view of his foot. These can be prodigious when looking at these views of the foot. And yet, interestingly, they rarely have any relation to pain experienced on the bottom of the heel. Many of us have these large protruding bone spurs on our heels but are typically oblivious to its presence since it does not directly cause pain.

An obvious question concerns their formation; why do these bony growths develop? Likely, the mere mention of Wolff’s Law will suffice. But seriously, those educated on the topic will recognize this important dictum regarding the response of bone tissue to stress. Our arch ligament attaches at this area of the heel and, depending on a multitude of factors, the pulling on the bone by this ligament-like structure can elicit bone growth in response.

Joe had obvious pain relief after the shot, but no medicine can dissolve bone so how did it provide benefits? Cortisone is a common example of a steroid medication, in this case a corticosteroid. These are effective at altering the inflammatory process, which develops in one’s arch ligament (the plantar fascia) in certain foot types and with certain activities. But when the cause of the inflammation is still present, such as an arch which collapses, the relief will always be temporary, and the pain will return.

Spur removal was the fashion years ago but is considered inappropriate by experts today. Previously, we didn’t appreciate the contribution to foot function by the fascia. It’s an important part of the mechanical changes occurring with each and every step. When the spur was removed, the surgeon, by necessity, had to detach the plantar fascia, which is your arch ligament.

Because the fascia was released, the operation provided some relief, but, too often, recovery was difficult and complications ensued. Unfortunately, releasing the fascia remains a frequent procedure for the treatment of plantar fasciitis. Yet, even if only a partial release is performed, this approach too often has ramifications. Without its tethering effect, the arch moves abnormally, and joints can be stressed, ligaments pulled, tendons overworked.

Acute plantar fasciitis of recent onset can sometimes be resolved with simple measures, a change of shoe gear, more stretching exercises, or short term use of an anti-inflammatory. But for every one of these sufferers there are three in which the pain doesn’t resolve so easily. Or it returns, sometimes repeatedly. For some, plantar fasciitis is a curse. How do you do much of anything if you can’t put weight on your heel?

Numerous beneficial conservative treatments exist, like the application of a specialized taping that rests the plantar fascia. Traditional physical therapy modalities, like ultrasound, electric stim, and others, all can be helpful but how much is needed will vary based on a multitude of factors. The severity of this condition varies greatly which is why an individualized approach is best. Many have a tight Achilles tendon, a significant contributor to this condition, so a stretching regimen can be helpful.

The most important treatment for many people with chronic or recurrent plantar fasciitis is some sort of arch support. These in-shoe braces for the feet can do many things, but the benefits depend on the construction of the device, the shape of the support, how it matches the foot, how well it controls motion of the heel bone, and numerous other components of the complex process that is foot and leg biomechanics. A prescription device is made from a copy of the foot, although the accuracy of the copy varies greatly depending on the technique used.

There are minimally invasive surgical procedures for plantar fasciitis which serve to remove the diseased portions of the fascia. Recovery is simple and the success rate high. But rarely is any surgery necessary to resolve this ubiquitous condition. Estimates as high as one out of five us will experience heel pain at some point and achieving resolution of the pain can be challenging. But a thorough assessment of your biomechanics, providing critical information regarding the cause for your heel pain, will go a long way towards achieving relief.

Dr. Conway McLean, DABFAS, FAPWHc, has offices in L’Anse and Marquette. He is a physician who specializes in treating lower leg, ankle and foot problems.


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