1: Make the Correct Diagnosis:
NOT ALL HEEL PAIN IS THE SAME. Heel pain can be caused by various factors. Most commonly, inflammation or degeneration of the plantar fascia is the major cause of heel pain. Additionally, neurologic origins of heel pain can play a major role. Sometimes there are less common etiologies like bursal inflammation, fat pad atrophy, bone bruise or even fracture of the heel spur. One misconception is that heel spurs cause pain. Heel spurs in and of themselves are generally painless. I have seen many patients misdiagnosed with heel pain and her treatments have been unsuccessful. In my opinion, The diagnosis of Plantar Fasciitis can really only be made with the use of an ultrasound. Without that it is just a guess. Many doctors believe the diagnosis for heel pain can be made by taking a good medical history of the pain and doing an exam. This is simply inadequate. I have been treating heel pain for nearly thirty years and the more experience I get, the more I am convinced how easy it is to be wrong without good objective data (an ultrasound image). Pain syndromes caused by different pain generators can have the exact same symptoms in the exact same spot. Careful examination is helpful but also can be misleading. I recently had a patient who had undergone 5 surgeries on her plantar fascia by over a period of several years with another doctor. Both feet were operated on several times. Her symptoms did not improve. I did a careful exam and discovered she had nerve entrapment. She may have had plantar fasciitis but she also had nerve pain that contributed to the problem. Unfortunately that was no addressed in her surgeries and her pain persisted. Se is no considering surgery for nerve decompression.
2: If Plantar Fasciitis is the cause of the pain then it must be staged.
The staging of Plantar Fasciitis means that the degree of change in the duration of pain are taken into consideration when considering the treatment protocol. Heel pain that has been present for 2 weeks is simply not the same as heel pain that has been present for 2 years. The first may be inflammatory and the second is likely degenerative. Treatments need to be targeted to address what is going on in the tissues. An Ultrasound is critical in this step as well. The degree of degeneration, the amount of change within the tissues and the extent of the disease process can be adequately evaluated. An MRI could also be helpful. However, an MRI costs around $500 and an ultrasound costs about $30.
3: Be aware the possbility of multiple causes of heel pain.
Sometimes, in a busy practice, its easy to be short sighted. It is critical that all the pain generators are identified addressed in trying to treat heel pain successfully. In chronic heel pain (pain that has been present for more than a few months), more often than not there are more than one pain generator. All causee need to be addressed.
4: Target appropriate treatments for the correct diagnosis.
Treatments need to be targeted and aggressive. In our office, if a patient is not substantially better in 2 weeks, then we are looking for different options. It simply makes no sense to give a steroid injection (which is the treatment for inflammation) for a condition that is degenerative in nature. Temporary symptomtic relief might be obtained at the tissue has not been healed or helped. It makes me last to read recommendations of treating heal pain for 6 months. Some of the more advanced treatments include EPAT Therapy and Amnion injections. These have shown great promise to heal the tissues.
5. Ongoing Treatment
A significant amount of patient involvement is required for successful treatment of heel pain. If you don’t perform home exercises, use good arch supports, if required, or other treatments and therapies. The condition is likely to come back or more accurately–it probably didn’t heal completely. This ongoing treatment can be things to do at home such as stretching, arch supports or orthotics, night splints, if needed, medication and physical therapy. It takes several months for the tissues to heal adequately. I recently had a conversation with a wellness doctor and made it I think a very insightful statement: “The future of medicine is in the kitchen”. Adequate nutrition with collagen, Vitamins, Glucosamine are all important to heal the tissues.