A fairly typical case example of plantar heel pain was presented in this forum two weeks ago. Last week, there was a discussion of a custom foot orthotic build to treat plantar heel pain. This week, I would like to present an informal general discussion of plantar heel pain, its root cause in many cases, various treatment options including custom foot orthotics as an essential part of the treatment toolbox, and most importantly, how to manage patient expectations.
Controversy surrounds the subject of plantar heel pain. Many seminars in the podiatric world have contained symposia and panel discussions on how to deal with this problem. Five esteemed panelists would offer their respective opinions, they would all differ, and eventually agree to disagree. Reasons for the rapid increase in cases during the past few decades included obesity (it doesn't help, but skinny people get heel pain too) and hard walking surfaces. I practiced in Southern California, where concrete foundations are the norm, and would often hear patients tell me their heel pain was improved when they traveled out of the area, but would recur when they came home. Modern shoe construction may be contributory, light materials that cushion, but don't support as well, can lead to foot problems for many, especially after long hours on one’s feet. Opinions vary on this, and discussions will continue indefinitely.
Treatment of plantar heel pain is also a topic for much discussion. Many of you reading this see plenty of this every day, and most certainly have your “go to” treatments. The temptation of the quick fix is often difficult to resist, especially when the patient has tried unsuccessfully to fix it themselves for the past three months. The reality is that plantar fasciitis/fasciosis/fasciopathy is an overuse syndrome, most often with an underlying biomechanical etiology, and treatment goals should be for not only short term symptomatic relief but long term permanent management of the condition. Patients should understand phase one is “get you better” and phase two is “keep you better”. My evolution in treatment went from steroid injections, NSAIDS and heel cups, to low dye straps (my go to for quick results) dorsal night splints, walking boots, magnetic resonance imaging and a lot more PT referrals (no pain, no gain type). And patience. The vast majority of patients would ultimately be put into a functional orthotic, often similar in type to the KevinRoot Medical P13 model, coupled with a supportive type shoe, but not always.
Patient management is very important in achieving successful outcomes. Much about the condition is counterintuitive. Walking barefoot on a sandy beach is brutal to a heel pain patient. Explain why. Restricting activities, either voluntary or by use of an assistive device such as a boot or cast will take advantage of the power of rest. Something very few people want to do. Can one reasonably expect a headache to go away if they keep banging their head on the wall? But that is what we expect with heel pain. Make it make sense.
Finally, no two cases are identical. My analogy for patients was describing an ice cream sundae. Plain vanilla is post-static dyskinesia, no pain off weight bearing, as the predominant symptom of a relatively short duration, 3 weeks or less. Add hot fudge, chopped nuts, whipped cream and a cherry on top, with such things as bone marrow edema on a T2 MRI image, partial or complete tearing of the fascia, Baxter’s neuropathy, tarsal tunnel syndrome, lumbar radiculopathy, fat pad atrophy, sinus tarsitis, Achilles tendinopathy, rheumatological conditions, etc. etc.
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