Are You Treating Heel Pain Like A Specialist?

I often read and listen to colleagues describing their preferred treatment for plantar heel pain. I am surprised at how many podiatric physicians follow the same protocols typical of primary care providers. This raises a question: Why aren’t foot and ankle specialists really practicing like foot and ankle specialists?

If a patient presents to a podiatric physician with plantar heel pain and gets a prescription of the usual regimen of calf stretching, ice therapy and non-steroidal anti-inflammatory drugs (NSAIDs), why would the patient need to see a specialist? Any patient can get this same advice on the Internet. If they rely on unproven and rather useless interventions, these patients will follow a long, protracted recovery.1

The validity of the following treatments has the support of my 32 years of clinical practice as well as good quality evidence in the medical literature. Most importantly, these treatments are based upon sound biomechanics and knowledge of foot function, things that set podiatric physicians apart from other specialties.

Treatment #1: Mechanical support. In most cases, plantar heel pain is the result of mechanical overload of the central band of the plantar aponeurosis.2 It is not an inflammatory condition and podiatrists should properly term it as a degenerative condition, i.e. “plantar fasciosis.”3 To relieve mechanical strain on the plantar fascia, I give almost all of my patients low-Dye strapping on the first visit and many then receive custom foot orthoses. Studies have proven both modalities to relieve plantar heel pain.4-6 For optimal results with custom foot orthoses, one must cast with a neutral suspension technique. Clinicians should take additional steps such as maximally pronating the midtarsal joint while plantarflexing the first ray to capture an everted forefoot to rearfoot alignment so orthoses will provide a “lateral forefoot wedge.” Kogler and colleagues have validated this wedge effect to offload the central band of the plantar aponeurosis.7

Treatment #2: Tissue specific stretching. Di Giovanni and colleagues advocate teaching patients plantar fascia specific stretching.8 This technique is superior to calf stretching.8,9 While physical therapists may be familiar with this newer technique, most primary care doctors are not.

Treatment #3: Corticosteroid injection. I do not hesitate to inject the plantar fascia with combination short- and long-acting betamethasone. The scientific literature shows good evidence supporting the efficacy of this treatment.10 While plantar fasciosis is not an inflammatory condition, a corticosteroid is one of the few substances that can reverse some of the stages of this degenerative condition, particularly collagen hypertrophy.11 Podiatric physicians are the most skilled at administering this injection simply because we know the anatomy and we do more of these injections than anybody else.

Treatment #4: Footwear modification. My years of experience have proven that identifying and eliminating faulty footwear is an essential part of the treatment plan for plantar heel pain. Knowledge of footwear is essential for the podiatric physician and should set us apart from other specialties.

Treatment #5: Radiofrequency nerve ablation. A low-cost and safe modality to treat recalcitrant plantar heel pain is radiofrequency ablation of the inferior calcaneal nerve (also known as “Baxter’s nerve”). Not only is this procedure indicated for a nerve entrapment, clinicians can use the modality to relieve the pain of chronic plantar fasciosis. In both conditions, 80 percent of patients receive significant long-term relief with no risks or complications.12

The podiatric physician can best implement these treatment approaches. These interventions are not well known nor are they part of mainstream treatment by primary care doctors. These modalities are certainly not easy to implement by reading about them on the Internet. If patients seek a foot and ankle specialist to obtain relief of plantar heel pain, the treatment they receive should reflect the specialized training and knowledge that podiatric physicians have.

References
1. Crawford F, Atkins D, Edwards J. Interventions for treating plantar heel pain. Cochrane Database Syst Rev. 2000; (3):CD000416.
2. Wearing SC, Smeathers JE, Urry SR, Hennig EM, Hills AP. The pathomechanics of plantar fasciitis. Sports Med. 2006; 36(7):585-611.
3. Lemont H, Ammirati KM, Usen N. Plantar fasciitis: a degenerative process (fasciosis) without inflammation. J Am Podiatr Med Assoc. 2003; 93(3):234-7.
4. Lynch D, Goforth WP, Martin JE, Odom RD, Preece CK, Kotler MW. Conservative treatment of plantar fasciitis — a prospective study. J Am Podiatr Med Assoc. 1998; 88(8):375-80.
5. Lee SY, McKeon P, Hertel J. Does the use of orthoses improve self-reported pain and function measures in patients with plantar fasciitis? A meta-analysis. Phys Ther Sport. 2009 Feb;10(1):12-8.
6. Hawke F, Burns J, Radford JA, du Toit V. Custom-made foot orthoses for the treatment of foot pain. Cochrane Database Syst Rev. 2008; (3):CD006801.
7. Kogler GF, Veer FB, Solomonidis SE, Paul JP. The influence of medial and lateral placement of orthotic wedges on loading of the plantar aponeurosis. J Bone Joint Surg. 1999; 81(10):1403-13.
8. Di Giovanni BF, Nawoczenski DA, Lintal ME et al. Tissue specific plantar fascia stretching exercise enhances outcomes in patients with chronic heel pain. A prospective, randomized study. J Bone Joint Surg. 2003; 85-A(7):1270-1277.
9. Flanigan R, Nawoczenski D, Chen L, Wu H, Di Giovanni B. The influence of foot position on stretching of the plantar fascia. Foot Ankle Int. 2007; 28(7):815-822.
10. Lee TG, Ahmad TS. Intralesional autologous blood injection compared to corticosteroid injection for treatment of chronic plantar fasciitis. A prospective, randomized, controlled trial. Foot Ankle Int. 2007; 28(9):984-90.
11. Ball EM, McKeeman HMA, Patterson C, Burns J. Steroid injection for inferior heel pain: a randomized controlled trial. Ann Rheum Dis 2012; 72(6):996-1002.
12. Landsman AS, Catanese DJ, Wiener SN, Richie Jr. DH, Hanft JR. A prospective, randomized, double-blinded study with crossover to determine the efficacy of radio-frequency nerve ablation for the treatment of heel pain. J Am Podiatr Med Assoc. 2013; 103(1):8-15.