Bottom of the Heel
Plantar fasciitis is treated by addressing two issues: inflammation and lack of structural support. I begin by decreasing the amount of inflammation causing the pain. This is done by using prescription anti-inflammatory medication, icing of the heel and arch, as well as often using an injection of corticosteroid , which is a medication type that actively reduces inflammation. Similar to the commonly known ‘cortisone shots’, these injections are given in a series of up to three, usually split apart by two weeks. The majority of my patients have full resolution of their pain following the injections, and most people average two injections to achieve this.
The tightness of the plantar fascia, as well as the heel itself on the leg, needs to be improved in order for the tissue to become more relaxed and less likely to become inflamed. This is accomplished through daily stretching exercises. Some of my patients need night splints to keep the foot stretched throughout the night, which I carry in the office.
The arch requires support to cease the continued strain on the fascia, which I immediately provide using premium arch inserts. I feature the medical grade Powersteps brand. These supportive and durable inserts are suitable for both flat foot support and high arch cushioning. Not only are they superior to the flimsy ‘supports’ sold in pharmacies, they are also sold at relatively the same price, and in some instances lower. These act as a temporary support during the initial treatment process, while long term support and strain prevention is provided by prescription orthotics. I am well trained in foot biomechanics, and provide high quality prescription orthotics that fit in a wide variety of shoes and are made from a specific mold of our patient’s foot held in a corrected position. They are modified based on bone structure, instability, and areas of skin pressure, and are built to last for many years. Orthotics keep chronic plantar fasciitis from returning after successful treatment, plain and simple.
If these measures do not alleviate the pain, I have numerous other treatment techniques available. These include physical therapy, immobilization of the foot in a walking boot, and surgical intervention. Surgery is needed in a very small number of overall heel pain cases, but is generally quite successful at relieving the symptoms. See the section on surgery for more information on specific surgical techniques.
Bursitis is treated somewhat similarly to plantar fasciitis. Heel bruises simply need icing and a short period of rest to fully recover.
Treatment of tarsal tunnel syndrome requires several components. These include reduction of the active inflammation, as well as control of the strain that causes the tissues of the back of the foot to tighten over the nerve. Inflammation can be reduced through icing, prescription anti-inflammatory medication use, and an injection of corticosteroid. The injection is directed into the tarsal tunnel, and can potentially resolve the pain by calming the inflammation around the nerve.
The foot needs to be stabilized to reduce strain to the inner side of the foot at the ankle. In very mild cases, this can be accomplished using premium arch inserts. Eventually, prescription orthotic inserts can be used in the long term to prevent the strain outright. Most cases, however, need more initial support of the foot on the ankle. I use high quality medical grade ankle braces that provide this support. Very serious cases may need to have the foot immobilized further, and pneumatic walking boots are available for those cases.
Other potential treatment options include physical therapy, short course steroid medications, and ultimately surgical release of the tarsal tunnel if conservative measures fail. See the section on surgery for more information on the specific surgical technique.
Back of the Heel
The treatment of Achilles tendonitis and the bone spurs that irritate it involve simultaneously restricting the tendon’s motion through support and increasing its flexibility passively through stretching. By reducing its motion with a specialized ankle brace, the Achilles tendon can be supported and daily activities can continue with minimal harm to the injured tendon. Another variation of this for milder cases involves using a special heel lift that increases the slack on the Achilles tendon, leading to decreased strain when walking. Stretching exercises done passively, without the full weight of the body forcing the ankle upward, increase the ‘looseness’ of the tendon, making it less prone to strain and continued injury. It is vital that these are performed several times a day.
Inflammation is treated with anti-inflammatory medications and icing. Unlike other causes of heel pain, injections are not used near the Achilles tendon as the medication can weaken the tendon and cause it to rupture.
Physical therapy is also used to stimulate the healing process and to strengthen the tendon fibers. This is sometimes necessary in cases of chronic tendonitis, or acute injuries that do not respond to initial treatment.
For spurs and Haglund’s deformities, shoe modification may be needed to reduce the irritation the back of the shoe has on the heel. Prescription orthotic inserts are also used to control heel rotation, and can be of value to prevent Achilles tendonitis from returning in treated cases where flat feet cause over-rotation of the heel bone and strain the tendon attachment point.
Finally, surgery is needed when patients do not improve with the above measures. See the section on surgery for more information on the specific surgical technique.
Scott R. Kilberg DPM 