Pain under the heel is one of the most common but least understood conditions affecting the foot. A recent review of the research literature demonstrates there is much misinformation regarding this condition.
Heel pain is due to inflammation of the plantar fascia
The plantar fascia is a dense band of tissue spanning from undersurface of the heel to the toes. Plantar fasciitis meaning inflammation of the plantar fascia, is the term most commonly used in the diagnosis of heel pain. A recent histological study of specimens taken from 50 surgical cases found marked thickening and fibrosis of the tissues with no evidence of inflammation. (Lemont, 2003) These findings are supported by others (Schepsis , 1991 and Tountas and Fonasier, 1996). The studies suggest that “plantar fasciitis” is better described as a degenerative fasciosis without inflammation, not a true fasciitis.
The absence of inflammation questions our long held assumptions and approaches to the management of heel pain using anti-inflammatory medication. The gastrointestinal and cardiovascular side effects of anti-inflammatory medication and the increased risk of rupture of the plantar fascia following cortisone injection should also be seriously considered. (Acevedo and Beskin, 1998; Sellman,1994)
Heel spurs cause heel pain
Many patients and practitioners continue in the belief that the heel spur is the source of the patient’s symptoms despite evidence to the contrary. But heel spurs seen on X-ray are considered an insignificant finding.
Lapidus and Guidotti (1965) studied 134 patients with heel pain affecting one foot only and found that: 43% had spurs on both sides, 39% had no spurs, 14% had spurs on symptomatic side only and 3% had spurs on opposite side only. Spurs have also been shown to be a normal anatomical variant with only 3% located within the plantar fascia. (Abreu, 2003). If spurs are shown on X-ray, they will have been present long before and long after the presentation of heel pain.
People with flat feet are prone to heel pain
There are very few good studies exploring this relationship. Three studies demonstrated no association between arch height, the degree of pronation (rolling in of the foot) and heel pain. (Warren and Jones, 1987; Warren 1984; Powell, 1998). The only biomechanical factor shown to be associated with heel pain to date is a loss of ankle dorsiflexion (forward bending). (Kibler, 1991; Di Giovanni, 2003). Improvement in ankle dorsiflexion has been shown to correlate with reduction in heel pain. These findings support the rationale for calf stretching as an important part of treating heel pain.(Porter et al 2002)
Custom-made orthotics are the treatment of choice for heel pain
Studies investigating the effectiveness of custom-made foot orthotics (shoe inserts) have shown that they are no more effective than other less expensive approaches including off-the-shelf arch supports, night splints and silicone heel inserts. (Lynch, 1998; Martin, 2001; Pfeffer, 1999). These studies suggest that cushioned off-the-shelf devices appear to be as or more effective, than custom made devices, are considerably cheaper.
- Abeu M, Chung C, Mendes L, Mohana-Borges A, Trudell D and Resnick D (2003) Plantar calcaneal enthesophytes: new observations regarding sites of origin based on radiographic MR imaging, anatomic and paleopathologic analysis. Skeletal Radiology 32:13-21
- Acevedo J and Beskin J (1998) Complications of plantar fascia rupture associated with corticosteroid injection Foot & Ankle Int. 19:2 91-97
- Kibler W, Goldber C and Chandler T (1991) Functional Biomechanical deficits in running athletes with plantar fasciitis The American Journal of Sports Medicine 19:1 66-71.
- Lapidus P, Guidooti F (1965) Painful heel: report of 232 patients with 364 painful heels. Clin Orthop 39:178-186
- Lemont H, Ammirati K Usen,N (2003) Plantar fasciitis. A degenerative process (Fasciosis) without inflammation. Journal of the American Podiatric Medical Association 93:3 234-237
- Lynch D, Goforth W, Martin J, Odom R, Preece C and Kotter M (1998) Conservative treatment of plantar fasciitis. A prospective study. Journal of the American Podiatric Medical Association 88:8 375-380.
- Martin J, Hosch J, Goforth W, Murff R, Lynch M and Odom R (2001) Mechanical treatment of Plantar fasciitis. A prospective study. Journal of the American Podiatric Medical Association. 91:2 55-62.
- Pfeffer G, Bacchetti P, Deland J, Lewis A, Anderson R, Davis W, Alvarez R, Brodsky J, Cooper P, Frey C, Herrick R, Myerson M, Sammarco J, Janecki C, Ross S, Bowman M and Smith R (1999) Comparison of custom and prefabricated orthoses in the initial treatment of proximal plantar fasciitis. Foot & Ankle International 20:4 214-221.