The latest technological medical advances in alleviating runners’ heel
pain
I think I could have a
practice of patients with just heel pain. A day does not go by where I don’t
have anywhere between 5 and 10 patients who complain of chronic heel pain.
Plantar Fasciitis
When patients come to me with
heel pain, I feel their foot. It might be a little warm and tender in a certain
spot. If they have had the pain for only under a month, then it’s probably a
condition called plantar fasciitis.
The plantar fascia is a
thick, fibrous, elastic band of tissue in the inner bottom side, or medial
part, of the heel bone that stretches to the ball of the foot. What it does is
support the long arch of the foot. As you walk or run and your foot alternately
flattens and rises, the plantar fascia moves back and forth. With overuse,
sometimes it can get stretched beyond its norm. In extreme cases, it can tear
slightly. The body’s normal response is to try to repair the inflammation by
sending lots of blood and healing tissue to that area.
My patients want to be
involved in their healing process. So, I use a diagnostic ultrasound machine
and show them what and where their fascia is, where it is pathological (meaning
thickened), and how it moves when their foot moves. Plantar fasciitis responds
well to conservative treatment: namely, rest, ice, anti-inflammatory
medications, and usually some kind of over-the-counter support and taping of
the area.
Chronic Heel Pain
Other patients of mine
complain of heel pain they have had for over three months. They’ll come in with
multiple pairs of shoes and maybe over-the-counter arch supports or some
prescription orthotics and other kinds of apparatus and splints they’ve worn.
And they’ll say, “Doc, it’s killing
me. It’s affecting my activities and my daily living.”
When it gets to that and the
patients say they are compensating and now feel pain on the outside of their
foot or their knee, or that their lower back is starting to hurt, it’s a
chronic issue that needs to be addressed. Many of these patients are seeking relief
from their physicians, and they are receiving ineffective care in the form of multiple
cortisone injections in the heel to try to resolve this condition.
Now, there’s nothing wrong
with cortisone injections, but they have to be used judiciously. In my
practice, I might give you one or two. If the condition is not responding, then
it’s time to move on. With multiple injections the steroid decreases
inflammation, but it also decreases healing, thus weakening the area and making
it more susceptible to further damage or tearing.
That’s what happens with a
chronic situation. The band of tissues starts to tear and repair, tear and
repair. The patient will tell you that when they wake up in the morning, the
first step out of bed is very painful. What happens is that the first step down
in the morning is unsupported, the tissue rips again. That sets up the cycle of
tear and repair and healing.
Over time, you get scarring
to that area. You no longer have inflammation. So, those typical treatments
that would help respond to the plantar fasciitis won’t work anymore because you
now have a fibrotic area, meaning an area that’s lacking blood supply and the
ability to heal.
Remedies for Heel Pain
Shockwave Therapy
In these situations you have
to consider implementing newer technologies. One that I use in my practice is
extracorporeal shockwave therapy, which sends an acoustic wave across the foot from
the outside to the inside and creates tiny holes as it penetrates the fascia.
This causes an irritation to the area of the fascia where it is scarred,
causing it to bleed a little bit and thus accelerate the healing process. It’s
almost as though we were opening up and scraping away all the scar tissue, but
the treatment is via this external source, the shockwave.
Shockwave is done on
consecutive weeks, usually anywhere from one to five weeks. Patients respond
really well to this. We also use this procedure for other types of tendinopathies,
like Achilles tendinitis and anterior shin splints. The good news about this
treatment is that patients can continue to perform their activities (running,
biking, hiking) while they are receiving the treatment. Patients might not feel
a complete resolution of symptoms for a couple of months. But for the most
part, 80 percent of the population does very well with this.
Tenex
Another treatment that has
really been a game changer for heel pain in my practice is a technology called
Tenex. What we do with Tenex is perform a microscopic type of plantar
fasciotomy. We cut and remove a portion of the tissue using a small, hand-held,
pen-like probe that is introduced into the plantar fascia through a small
incision on the inside of the heel.
This procedure must be
performed in a surgical center or a hospital. There is downtime. The patient
has to take it easy for one week, walking in a post-operative boot with minimal
weight bearing. After a week’s time there is some kind of post-treatment
therapy.
Physical therapy works very
well for these patients. They are instructed how to manipulate the foot so they
can decrease the amount of scar tissue in that area. Once the foot feels
better—and patients usually do feel better right after the Tenex procedure—the
patients’ balance and symmetry are off. The therapist will work with the
patients to help strengthen their core so that the problem doesn’t recur. After
a week in the boot, we get the patient into a soft shoe or sneaker. We don’t
get them back to doing their regular athletic routines, especially any pounding
type of activities, for three to four weeks. They need that time to heal.
The great news about Tenex,
and why we say it is a game changer, is that we notice that patients have over
90 percent success rate after having this done. Tenex addresses not just the
symptoms, it addresses the cause. It brings new blood flow to the area that was
once void of circulation, making it healthy again. It gets that mobility of the
fascia back to normal.
Sometimes we’ll incorporate
both procedures, Tenex and Shockwave, if need be. But what’s really great
is to have in your toolbox both of these modalities to get the patients where
they need to be.
By Robert M. Conenello, DPM, FACFAS
Clinical Adviser, Special Olympics, Fit Feet
Past President American Academy of Podiatric Sports Medicine
