Fasciitis Treatment
Posted by admin on April 1st, 2009
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My Heel Pain Is Killing Me
Can it be plantar fasciitis?
Heel pain is one of the most common painful conditions seen in an arthritis clinic. This article discusses the various types of problems that cause heel pain and what can be done to make the situation better.
It’s estimated that more than 1 million persons in the United States suffer from heel pain at any given time.
When a patient complains of heel pain, it must be clarified by history whether the pain is in the bottom of the heel or the back of the heel because the diagnosis and treatment are very different.
Pain in the bottom of the heel is often due to plantar fasciitis (PF). The plantar fascia is a tough band of tissue that begins at the medial (inside) part of the bottom of the heel and extends forward to attach at the ball of the foot. The fascia is responsible for maintaining the normal arch. When an excessive load is placed on the fascia, pain can develop at the origin (the heel) as well as the mid-portion (arch) of the fascia.
PF can develop in anyone but is more common in certain groups such as athletes, people older than 30 years of age, and obese individuals.
PF must be distinguished from other causes of bottom of the heel pain such as nerve entrapment, atrophy of the normal heel fat pad, stress fracture of the calcaneus (heel bone), rupture of the plantar fascia, bone cyst, bone tumor, and bone infection.
The history typically describes a gradual onset of symptoms with no prior trauma. The most telling symptom is severe pain in the bottom of the heel when taking the first morning step. Patients may report difficulty walking to the bath room. The pain tends to lessen with more walking. This ‘first step’ pain is also present during the day if the patient has been sitting for awhile, then getting up to walk.
On exam, pain is noted with pressure applied to the medial bottom of the heel. Tenderness is worsened by pointing the toes and ankle toward the head. This is because the plantar fascia is being stretched. Pain in the arch may also be present.
One in older patients should be ruled out and that is heel pad atrophy. Normally the heel has a thick feeling to it. In older patients the heel pad may lose this thickness and flatten out. The pain is located more centrally.
Another ‘fooler’ is entrapment of the lateral plantar nerve. Pain is felt in the medial heel but may be present at rest as well. There may be weakness spreading the toes.
Fracture of the calcaneus (heelbone) causes pain at rest that is worsened with walking. Tenderness is present along the sides of the heel. Magnetic resonance imaging (MRI) can confirm the presence if fracture.
But what about ‘bone spurs’? The presence of a bone spur by itself means nothing. They are very common and by themselves are not a cause of pain. Some patients with inflammatory forms of arthritis such as psoriatic arthritis, ankylosing spondylitis, or Reiter’s disease have a specific type of spur that should prompt further evaluation looking for systemic forms of arthritis.
Diagnostic studies such as ultrasound and magnetic resonance imaging can be used to confirm the presence of plantar fasciitis. Electromyography (EMG) may be needed to rule out lateral plantar nerve entrapment.
How is this condition treated?
The first thing is to institute a stretching regimen. Most people with PF also have a shortened Achilles tendon and the ability to dorsiflex (point the toes up) is limited. The plantar fascia is continuous with the Achilles fascia. Stretching the plantar fascia and the Achilles decreases the tension in the plantar fascia and helps relieve inflammation.
A temporary reduction in activity is important in athletes, particularly runners. Cross training with swimming and cycling can help maintain cardiovascular fitness while sparing the plantar fascia from pounding. Runners should avoid hills and make sure that any foot abnormality be corrected with custom orthotics.
Ice massage with ice cubes applied to the plantar fascia can also be helpful.
Shoes with soft heels and inner soles can relieve discomfort. Rigid heel cups and arch supports are generally not recommended. The patient may gradually resume normal activities over an eight week period of time. Rushing rehabilitation is not advised.
If there is no improvement, a night splint which holds the ankle in 10 degrees of dorsiflexion prevents the shortening of the plantar fascia.
If the night splint fails or the pain does not lessen, injection of glucocorticoid (cortisone) using ultrasound guidance is recommended. Injections should be limited to a maximum of two given over four weeks.
Patients who do not get better need to be reevaluated for systemic disease or other conditions causing heel pain.
Surgery is the last resort. Transverse release of the plantar fascia is the procedure of choice. This can be done using arthroscopic guidance.
Pain in the back of the heel is an entirely different condition. The major structure here is the Achilles tendon which extends down from the gastrocnemius muscle to attach at the rear of the calcaneus.
Inflammation of the Achilles tendon can occur, usually in athletes or in people in engage in overxuberant physical activity involving running or jumping. Patient who are overweight are also at risk. The pain is usually described as a soreness. There is localized swelling and tenderness. Ultrasound can be used to differentiate an inflamed Achilles tendon from one that is partially or fully torn. The treatment involves anti-inflammatory medicines, physical therapy, and stretching exercises. Glucocorticoid injection is not recommended because of the danger of weakening the Achilles tendon leading to rupture. Using a foam rubber lift to elevate the heel in a shoe can help with symptoms.
Achilles rupture is handled surgically and requires a long recuperation.
Haglund’s syndrome, which is a condition where a spur develops at the back of the calcaneus and is often associated with localized Achilles tendonitis can also cause pain in the back of the heel. Ill-fitting shoes are the most common cause. Typically a bump develops at the back of the heel. Because of its association with ill-fitting shoes, this is sometimes referred to as a ‘pump bump.’ Physical therapy, anti-inflammatory medicines, and stretching can often be of benefit. Glucocorticoid injection should be sparingly employed because of the danger of Achilles rupture. Wearing proper fitting shoes are an obvious adjunctive treatment.
Bursitis involving the retrocalcaneal bursa (the small sack that lies between the Achilles tendon and the calcaneus is a cause of pain behind the heel. Treatment involves the use of physical therapy modalities such as ultrasound. Sometimes glucocorticoid injection may be needed. It is important to limit the injection to one because of the danger of possible weakening of the Achilles tendon leading to rupture. Ultrasound needle guidance is advised to ensure proper localization of the injection.
The diagnosis is made by history and physical examination. Both MRI and ultrasound can be used for confirmation.
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Nathan Wei MD FACP FACR is a rheumatologist and Director of the Arthritis and Osteoporosis Center of Maryland. For more info: Types of Arthritis
Remeber to check out the brilliant guide to cure your heel pain: "Plantar Fasciitis Secrets Revealed". Find out how this has helped many others by clicking here.
More information can be found on the following pages: Plantar Fasciitis Relief – Plantar Fasciitis Treatment – Chronic Plantar Fasciitis & Exercise – Plantar Fasciitis Surgery & Cure – Plantar Fasciitis Splint – Shoes & Plantar Fasciitis Running – Foot Pain Symptoms – Plantar Fasciitis Orthotics – Fasciitis Treatment.
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Plantar fasciitis is a quite common, very painful foot problem caused by repeated tension on the plantar aponeurosis.
Is Plantar Fasciitis causing that throbbing pain in your foot every morning? Do you feel it as you make an attempt to make a step out of the bed as soon as you wake up in the morning? Well, it can be really unbearable and it occurs daily without any exception.
Take note that plantar fasciitis is principally caused by strain and stress. It only goes to show that your choice of footwear influences the occurrence of the condition. Make sure to refrain from the use of shoes which offers little or no support at all on the bottom of your foot and the arch.
Cryosurgery, also known as Cryotherapy or Neuroablation, is a minimally invasive FDA approved procedure done in the office for pain relief and nerve problems of the foot. Dr. Katz notes that treatments have provided longstanding relief for heel pain, plantar fasciitis, Morton’s neuroma and neuropathy and many other painful conditions.
Researchers performing cryosurgery observed that extreme freezing had an anesthetic effect beyond the temporary relief produced by simple cooling. Over the last thirty years, many treatments have been introduced to address chronic pain by neurologists, surgeons, pain management specialists, and neurosurgeons. These techniques have had a common goal of producing prolonged nerve blocks to relieve intractable pain. Within the last ten years, cryosurgery has been utilized to relieve trigeminal nerve pain, lumbosacral pain and most recently carpal tunnel syndrome.
Heel pain is by far the most common foot complaint that affects millions of people around the world. Plantar Fasciitis is the ailment that is often associated with the symptoms of Heel Pain and Heel Spurs.
The Plantar Fascia generally takes the full load of the body when the foot is placed on the ground. This transmits great force and stretches the Plantar Fascia to even out and flatten the arch of the foot to distribute the weight of the body. The bow and string analogy appropriately describes the arching of the foot by the Plantar Fascia.
The foregoing "short-term" remedial measures assist in relieving heel pain. As Plantar Fascia excessively stretches due to over-pronation (fallen arches) and tightening of the calf muscle and ligaments it is advisable to undergo long term treatment that has recently been found to be quite effective.
If you experience a sharp pain in your heel at the first step in the morning, chances are you have plantar fasciitis (plan * tar fash* ee * I * tis). "Plantar" means the bottom of the foot. The "fascia" is a long ligament type structure. "Itis" means inflammation.
2. Try an ice massage: Freeze a sports water bottle and place it on the floor. Roll your arch over the water bottle for 20 minutes twice a day.
5. Wear supportive shoes: This step may seem logical, but most individuals don’t realize how poor their shoes are. A supportive shoe will bend only where the foot bends, at the toes. To test this, take your shoe and flip it over. Grab the toe area and the heel and try to fold the shoe. If the shoe bends in half, then the shoe is not supportive. You should wear supportive shoes at all times.