Heel Pain – Conservative Treatment Options By Dr. Leonard Vekkos, FACFAS, FACFAO soft tissue as with steroid.And stem cells can be administered as often as needed because of the healing benefit for the tissue.
The biomechanical reasons for heel pain origin directly relates to the function and structure of our feet. The most important structure involved in the etiology of heel pain is the plantar fascia, a strong, thick ligament that runs from the heel to the ball of the foot attaching finally in five separate bands to the bottom of each toe. It is the excessive stress placed on this ligament which causes the ligament to pull on the bottom of the heel and produce irritation of the covering of the bone. It is this irritation that causes the pain. When considering treatment for heel pain (plantar fasciitis) first and foremost we must work to resolve the current pain which has become the focus of the patient’s complaint, but just as importantly, we also need prevent the pain from recurring. Often, self care can resolve your symptoms. Simple stretching of your foot before you get out of bed will lengthen out the plantar fascia and reduce if not eliminate the pain. Wearing an over the counter arch support or more supportive shoes can help significantly. Over the counter anti-inflammatory medication can also help with the pain, but it does not address the reason for the pain.While self treatment may help to alleviate the heel pain, it is usually temporary at best in acutely painful or chronic conditions. As a result, concomitant physician-directed treatments are usually necessary. My approach to treatment is two-fold (1) treat the current pain and (2) prevent it from coming back. Treatment of the pain is best approached directly. I have found that injection therapy achieves this best. Using a combination of local anesthetic and cortisone, the heel is approached through the medial (the inside part of your foot) side directly over the painful
Placing patients in a below-the-knee cast may also be effective for pain relief through immobilization of the ankle and therefore reducing the stress throughout the plantar fascia. However, in over 30 years of practice, I have found it only in rare instances.
area. It is NEVER necessary to inject through the bottom of the foot as this is an extremely painful approach and has no advantages. The combination is injected and relief of pain is seen within 2-3 minutes. This injection accomplishes several objectives. First, the use of local anesthetic allows for immediate pain relief through numbing of the area. The patient walks out of the office with 100% relief of pain. However, this initial pain relief is temporary and will be effective for only about 2-4 hours after which time the cortisone will continue to work. Second, because the nature of cortisone is create inflammation before it reduces it, patient’s may experience what is called a “post-injection flare reaction”. I instruct the patient to apply ice or take an over the counter anti-inflammatory and it usually resolves within in a day two. But the long term effect of cortisone is to reduce the inflammation associated with the plantar fasciitis. What is also exciting is the recent development and use of stem cell injections for heel pain. I have seen an improved response with stem cell injections compared to steroids and the advantage is there are no deleterious effects on the
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Preventing the pain from returning is a multifaceted approach. Due to the plantar fasciitis resulting from abnormal flattening of the arch or stress from a high arch, a simple removable strap and pad custom made on the patient’s foot is worn for two weeks while the injection is doing its job. I may also prescribe physical therapy for stretching of the ligament and local ultrasound therapy. Depending upon the patient’s response, custom molded orthotics (arch supports) may be manufactured. Orthotics are highly specialized devices prescribed by a podiatrist using specific measurements and requiring special labs to make them. These work to normalize function of the foot and reduce stress on the plantar fascia. Overall, I have found that over 90% of heel pain responds to conservative measures. While the time it takes to achieve resolution varies from patient to patient, a favorable outcome is usually accomplished through the above conservative measures.
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In regards to using prescription drugs for pain relief and anti-inflammatory effect, I advocate all attempts at a medication-free treatment plan and have had excellent results over the past twenty years with this approach obviating the need for any drugs, whether prescribed or over the counter.
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