Heel Pain ~ Plantar Fasciitis & Heel Spur... more than meets the eye

Let's not bore you with numbers/stats about the percentage or frequencies of heel pain or how much it cost the health-care system to treat heel pain sufferers. It’s a prevalent complaint that frustrates a lot of the sufferers and the professionals that encounter them.

Myths about Heel Pain:

• Myth ~ Heel spurs cause heel pain and need to be surgically removed.
  
  • Fact - there's a poor correlation with x-ray findings of heel spurs with heel pain (ie. incidental findings of heel spur without pain or tremendous pain with no heel spur ~ go figure?!) It is not recommended to have the spur surgically removed because it leads unnecessary tissue damage... prolonging the resolution of the pain.
    

• Myth ~ Inflammation is the cause heel pain.
  
  • Fact - inflammation is the natural healing process of the body. It's a 'signal' of tissue damage and that the body is trying to isolate and heal the damaged tissue. It's the result of repetitive stress onto the heel that prevents incomplete healing.
  
  
• Myth ~ Plantar fasciitis is the cause of the heel pain.
  
  • Fact - it is unlikely that the Plantar Fascia is the only tissue involved. There are a lot of tissues at the heel area. Many of them run very deep and oftentimes, are not addressed/treated properly. The pain is due to the scarring of the layers of tissue, inhibiting circulation and flexibility of the area.
  
  
• Myth ~ Rest is the best thing for the heel pain.
  
  • Fact - rest will only minimize the irritation of the irritated tissues. The scarred tissues will not go away on its own. It's best addressed with a pro-active attitude with ice, manual therapy (e.g. Active Release Technique, Graston Technique, Shock Therapy etc.), proper stretching and strengthening exercises.
  
  
• Myth ~ Night splint will make the heel pain go away.
  
  • Fact - it's a very passive and awkward means of addressing it. The thought behind this tool is to keep the ankle/foot in a dorsiflexed position overnight to minimize tightening of the Achilles & Plantar Fascia. I've heard of people sleeping with it every night for months with unimpressive results. Night should be used temporary rather than long term solution.

Typical Pain Pattern...

• gradual onset, without any association with trauma
  
• stabbing-like pain at the heel, commonly at bottom front edge of the heel bone where the Plantar Fascia & other muscles are attached
  
• first-step pain ~ most noticeable in the morning as the foot strikes the floor or after a prolonged period of rest
• pain tends to reduce to a dull ache as the day progresses
  
• with pressure, the arch is very tender
  
• with pressure, the rim of the heel pad is very sensitive
  
• unable to heel walk due to sensitivity of the heel bone
  

Contributing factors...

• history of wearing high heels ~ shortened Achilles Tendon, which leads to greater tension onto the bottom side of the heel bone
  
• history of wearing non-supportive footwear ($10 flip flops without arch support ~ engages faulty windlass motion & creating excessive lateral motion of the calcaneus)
• excessive elliptical machines usage
• faulty running mechanics
  
• after pregnancy
• tight Achilles Tendon

Anatomy of the foot & ankle…Let’s discuss a bit about the anatomy of the foot & ankle, and the makeup of heel pain.

(This section is more than you need to know, but as always, knowing is half the battle. The take home message in the section is to make sure when you seek medical attention, the physician addresses the anatomy with you and identifies the source of pain.)

Feel free to skip past this section and scroll down to the Home Regimen and Professional Help section.)

Bones ~ 27+ bones in the foot (Talus, Calcaneus, Navicular,Cuboid, Cuneiform [3], Metatarsals [5], Phalanges [14], Sesamoid bone [1+]). The ‘+’ is the non-uniformity of the formation of the seamoid bones underneath the big toe. Some people have 1, some heave 2… the seamoid bone functions to better the bio-mechanical configuration of the muscles & tendons attached to the clumsy big toe.

Muscle, Tendons, Ligaments & Joints ~ what can be said about the muscles, tendons, ligaments & joints ~ there are a lot of them.

Muscularly, there are multiple layers of tissue on the bottom of our feet. The first layer deep to the skin is the infamous yet unusual suspect, the Plantar Fascia. The next 3 layers of muscles, 14 out of 18 are found in the foot, where the other 4 muscles originate somewhere in the leg and extend themselves down into the foot via tendons. Keep in mind; this is just the bottom part of the foot. Significant to heel pain, there are 4 muscles attached to the heel bone. Also there's the Achilles tendon that attaches itself to the back of the heel bone (aka calcaneous), with the Gastronemius & Soleus at the other end of the tendon.

Ligaments-wise, counting them simply undermines their functional importance. There are at least one gazillion ligaments between 2 bones. Each ligament acts to counteract the forces between the bones.

Joints ~ the first one that comes to mind is the “ankle joint”, aka the Mortise joint, aka the Talocrural joint, is formed by the Tibia, Fibula, & Talus. It’s labeled as a hinge-type of synovial joint. But most anatomists negate the complexity of the joint and all that it does, and all that happens to/with it. The other joints, the transverse tarsal joint, and the tarsometatarsal joints are crucial to the formation and functionality of arch .

FYI ~ the Talocalcaneonavicular joint is the third ball-and-socket joint of the body.

Biomechanics of the Arch of the Foot ~ Windlass Mechanism
Windlass Effect is an engineering concept that describes movements of heavy loads. In the foot, windlass mechanism is essential for correct foot/ankle function – and the principle remains simple, and true to its engineering origin.

The Windlass Mechanism is coordinated by the layers of muscle, tendon, ligament and the bony architecture, to maintain arch height, foot rigidity and arch flexibility.

The windlass motion involves the toes extending upward, drawing tension to the muscles and ligaments at the bottom of the foot. This tension pulls all the bones together tightly to maintain height of the arch, converts the foot to a rigid structure, and transfer the forces to propel the body off the ground.

Without correct windlass function, the arch of the foot collapses and fails to act as an efficient lever, thus limiting the push-off power. Faulty or absence of the windlass mechanism will result in additional tension generated onto the structures of the foot. The repetitiveness of the usage of the foot/ankle will result in tissue insult/failure --> PAIN!

Home Regimen (anecdotal success)

• persistent stretching of the Achilles tendon.
• rolling the arch with a golf ball rolling ~ find the sore spot and just gently attend to it (roll in all different directions). If you push too hard onto the ball, your heel wouldn't like it very much. The weight of your leg onto the ball is much enough to loosen things up a bit
• Repeatedly picking up marbles (or wine-corks) with your toes ~ actively strengthening your muscles. Do it until the foot & toes get a tad bit tired, or until you're bored ~ several minutes everyday is a good start.
  
• Ice ~ ice the entire foot with a ice water. 10-15 minutes in the evening
• Heat ~ warm up the foot ASAP in the morning to loosen up the heel

Professional Help ~ If the heel is not feeling better after a week or 2 with some self TLC, seek professional assistance to help address the problem.

• Imagining study ~ a plain film x-ray may be a good start to determine that there isn't a more serious problem, e.g. stress fractures, bone contusion, cysts etc...
  
• Manual Therapy ~ address proper joint biomechanics with mobilization/adjustment of the foot/ankle bones combined with Active Release Technique, Graston Technique to the injured soft tissues (muscles, ligaments, and tendons)... this is a formula I've used to help a lot of amateur and professional athletes.
  
• Orthotics ~ this is a tricky one. The insole is meant to position the foot/arch in its most bio-mechanical advantageous position. It won't necessarily resolve the problem but least the foot/arch has some support. It's your preference if they are custom made at the podiatrist/chiropractor or store bought ones ~ whichever works for you. My favorite in-store insoles are the Superfeet