Heel Spur Treatment
1. What is a heel spur?
While the term heel spur may create the impression of a sharp bony projection on the bottom of the heel that pokes the bottom of our foot causing our pain. Painful heel spurs are actually a result of damage to the soft tissue at the bottom of the foot. While this may be confusing, we'll try to explain.
Heel spurs is the more common name for a condition that is medically referred to as plantar fasciitis or heel spur syndrome. Plantar fasciitis is a location oriented term that refers to the bottom of the foot(i.e. plantar warts). Fascia is a tough, inelastic band. 'itis'is a term used to describe something that is inflamed (i.e. tendonitis, bursitis).
Fascia tissue is located throughout the body, usually providing support to the musculoskeletal system, providing rigidity, much like guide wires support a cell phone tower. Together with ligaments and tendons, fascia allows our body system that allows us to be mobile. Plantar fascia (foot fascia) originates on the base of the heel and runs across the arch of the toes. The primary function of the plantar fascia is to support the arch of the foot.
What Causes a Heel Spur?
Your plantar fascia is a thick fibrous band of connective tissue originating on the bottom surface of the calcaneus (heel bone) and extending along the sole of the foot towards the toes.Your plantar fascia acts as a passive limitation to the overflattening of you arch. When your plantar fascia develops micro tears or becomes inflammed it is known as plantar fasciitis.
When plantar fasciitis healing is delayed or injury persists, your body repairs the weak and injured soft tissue with bone. Usually your injured fascia will be healed via fibroblastic activity. They'll operate for at least six weeks. If your injury persists beyond this time, osteoblasts are recruited to the area. Osteoblasts form bone and the end result is bone (or calcification) within the plantar fascia or at the calcaneal insertion. These bone formations are known as heel spurs.
This scenario is most common in the traction type injury. The additional bone growth is known as a heel spur or calcaneal spur.
3. What are the forms of Heel Spurs?
- Primary plantar fasciitis
- Secondary plantar fasciitis
Primary plantar fasciitis, plantar fasciitis results from a mechanical overload of the plantar fascia by the sum of intrinsic and extrinsic loads.
Secondary plantar fasciitis is the result of direct trauma to the fascia and systemic diseases, like arthritis, that may effect the attachment of the fascia to the heel bone (calcaneus).
We've seen how a 'heel spur' is not actually a bone problem, it is still important to have x-rays of the affected area. Even though heel pain is primarily a result of soft tissue damage, there are several conditions that can also cause heel pain.
- Stress fractures
Stress fractures are most commonly a result of a sudden abrupt force that. A common example would be a fall from 7 feet or higher.
What are the Symptoms of a Heel Spur?
- You'll typically first notice early heel spur pain under your heel in the morning or after resting.
- Your heel pain will be worse with the first steps and improves with activity as it warms up.
- When you palpate the tender area you may feel a tender bony lump.
How is a Heel Spur Diagnosed?
Heel spurs and plantar fasciitis is usually diagnosed by your physiotherapist or sports doctor based on your symptoms, history and clinical examination.
After confirming your heel spur or plantar fasciitis they will investigate WHY you are likely to be predisposed to heel spurs and develop a treatment plan to decrease your chance of future bouts.
X-rays will show calcification or bone within the plantar fascia or at its insertion into the calcaneus. This is known as a calcaneal or heel spur.
Ultrasound scans and MRI are used to identify any plantar fasciitis tears, inflammation or calcification.
Pathology tests (including screening for HLA B27 antigen) may identify spondyloarthritis, which can cause symptoms similar to plantar fasciitis.
Treatment Primary Plantar Fasciitis
There are four main types of treatment options:
- Biomechanical methods
- Anti-inflammatory methods
- Extracorporeal Shockwave therapy
The importance of Ice
Icing your foot is recommended as long as the inflammation is present. The cold temperatures help to slow down local metabolism in the foot. Depending on the type of injury, you may want to continue icing the area for as long as inflammation is present, even after the pain has subsided. This may mean icing the area during the entire rehabilitation process. It may be particularly beneficial to ice the area as you return to more strenuous activity.
There are many ways that you can ice your elbow. There seems to be 2 distinct methods:
- ice the area with a cold pack
- ice massage
The most common way is to simply put and ice pack directly on the foot. You can fill a ziploc bag with ice and just put that on the area, or you can use a gel cold pack. You can buy gel packs in many drug stores. It may be a good idea to wrap the ice pack in a light cloth so you don't freeze your skin. It can happen, so you have been warned.
My preferred way is an ice massage. The way we used to do this is to freeze water in a styrofoam cup. You then tear enough of the cup off so that you can massage the foot with the ice. As the ice melts, you tear off more of the cup
Biomechanical Methods: soles , shoe wear , heel cups
Plantar fasciitis is a mechanical condition. This is a fancy way of saying that plantar fasciitis results from forces exerted by the body as we walk. Mechanical conditions are often best treated with mechanical treatments.
An excellent example of a mechanical solution is to elevate the heel by wearing a 3/8 inch heal lift or wearing shoes with a higher heal or a wedged sole. Elevating the heel reduced the amount of tension on the CT band. It also changes the angle of the foot to the ground changing the way that the load is supported. This reduces the amount of damage to the plantar fascia during the day.
Stretching is another biomechanical method to help with heel pain is the stretch the calf muscle. Stretching the calf elongates the tissue in the CT band and reduces the amount of tension helping to re-balance the normal biomechanics of the foot and leg. This reduction is tension lowers the amount of damage created during normal walking activity.. Two great stretches are the Stair Stretch and our personal favorite the Wall Stretch. Other biomechanical methods include:
- Stretching splints
- Stretching slippers
- Heel cups
- Taping the arch ( see the section on taping the foot )
All these devices focus on changing the biomechanical properties of the CT band. While these devices may help provide very quick relief to the area, the key to rehabilitating plantar fasciitis is the address the entire CT band and not just the plantar fascia.
Anti-Inflammatory Methods: steroid injections, anti-inflammatory medications
Anti-inflammatory methods include steroid injections, oral anti-inflammatory medications such as aspirin, NSAID( Nonsteroidal Anti-Inflammatories) prescriptions, ultrasound, massage, topical medications and other methods to reduced inflammation.
The important thing to remember is that you are treating a problem that is caused by overuse or overloading. Anti-Inflammatories help us address the dull aching type that can progress throughout the day. They do not help with the sharp tearing pain (post dystatic pain )often experiences when you get out of bed.
Anti-Inflammatories deal primarily with the symptoms of pain and not the actually problem that is causing the pain. It is important to combine biomechanical methods of care with anti-inflammatory treatments.
Extracorporeal Shock Wave therapy( ESW )
Shockwave therapy uses a acoustic energy wave that is focused at the area of pain. It is believed that the shock wave causes micro-trauma to the area. This micro-trauma stimulates an intense focused inflammatory response that promotes healing at the insertion point of the plantar fascia.
Shock wave therapy requires a high level of energy and can be painful. Most patients in the U.S. have the procedure performed in an outpatient setting with twilight sedation ( MAC sedation). The procedure takes about 15 minutes to perform. Patients are able to walk on the foot the same day of treatment. Complications have been minimal. Most doctors advise continued stretching an limited activity for approximately 4 weeks after surgery.
The long term success of Shock Wave therapy has yet to be seen, although short term success rates have success rates of 65% -95%. The best success rates seem to result from treatments with high-energy shock waves. The OssaTron is a high-energy treatment option. ( December 2003 )
heel spur surgical treatment
Surgical options should be the last resort as they have the greatest risk of complications. Plantar fasciitis surgery has come a long way in recent years, even though the basic technique remains the same. The basic idea of surgery is to manually release the fascia of the foot with the hope that the pain will be eliminated, medically termed plantar fasciotomies.
Surgery has the risk of further complications dues to changes of the structural support of the foot. Possible complications include:
- Fallen arches
- Lateral Column Syndrome
- Nerve damage
What stretches help reduce heel pain?
There are many ways to stretch the calf muscles and tendons, the following stretches are what we have found to be the most effective.
This is a great stretch to do. Begin by finding a step, curb and something you can hold onto to maintain your balance. Remember to slowly ease into the stretch. Bouncing may cause further trauma to the area.
- Balance yourself on the balls of your feet
- Slowly allow your body weight to gently stretch the calf muscles until you feel tension.
- Hold this position for 30 seconds
While wearing shoes, locate a doorway.
- Reach through the door way so that you can balance yourself.
- Position one of your feet so that:
- The ball of the foot is firmly against the wall.
- The heel of the foot is firmly pressed into the ground.
- Begin to slowly apply pressure by pulling your body towards the wall, making your lower leg more perpendicular to the floor.
- Repeat with the other foot.
8. How can you prevent re-injuring the heel?
To avoid re-injuring the fascia and causing further pain, the APMA has the following recommendations:
- Always consult a foot specialist before starting a new exercise program
- Allow your body to adapt to the exercise program by starting slowly. It takes time for the body to adapt to the additional stress.
- Purchase and maintain good shoes and replace them regularly. Investing a little more money in good shoes will pay dividends in pain-free living.
- Remember to stretch your feet and Achilles tendon before and after exercise.
- Always try to exercise on an even surface. Uneven surfaces can but strange stressed on the foot and can result in pain.
- Avoid walking barefoot on hard surfaces. Without your shoes, you fascia has to support your entire body weight.
- If it hurts, STOP. Don't try to bear through the pain.