Foot pain not necessary

Conway McLean, DPM

There seems to be the general consensus that foot pain is normal, an expected consequence of modern life. I would bet the average joe, if questioned, would say feet have hurt throughout human existence. Although I cannot offer up any statistics on this issue, let me assure you, feet should not hurt. When they do, there is a reason, be it a structural or functional abnormality, some deviation from the norm, that leads to excess physical stress to some part of our anatomy.

Without question, the most common foot complaint is heel pain. The frequency with which this occurs is staggering, studies revealing at any one time, about 1 out of 10 people are experiencing some degree of discomfort from this region. Many individuals obtain recommendations concerning treatment from a neighbor or, even less accurate, from the internet. This may be shocking news, but not everything you read on the internet is correct or truthful. So much of what is posted is related to, or leads to an advertisement. Truth in advertising, for the most part, does not exist.

Heel pain is generally due to plantar fasciitis, whereby the ligament supporting the arch becomes the source of pain. An important facet of plantar fasciitis is the multitude of conditions that can ultimately lead to this problem. Therefore a “one size fits all” approach will usually provide insufficient relief. Many will some experience improvement with OTC pain medications, a change in shoe gear, or stretching exercises. But frequently, when this simpler method is discontinued, the relief obtained will be lost, the pain returning.

If these home measures do not produce relief of your heel pain, it is probably time to see a professional. With an accurate and detailed assessment of foot and leg anatomy, alignment and function, specifics about the root of the problem can usually be determined. Certainly, reducing the levels of biochemical inflammation will relieve acute pain, typically achieved with an oral anti-inflammatory (ibuprofen, naproxen, etc) or a steroid injection. For every one person who gets lasting relief from a “cortisone” injection, there will be nineteen who don’t. Too often, this is an approach aptly termed a “band-aid”.

Understandably, a little bit of research will reveal the importance of arch support. But there is tremendous variability in why someone develops plantar fasciitis, so a simple, pre-fabricated support, placed inside the shoe, will usually not do enough to reduce the strain on this troublesome structure. This means only temporary, transient relief. But everyone is different, and this is a simple initial treatment option that is worth attempting. Not everyone needs a custom support.

A multitude of reasons exist as to why someone develops plantar fasciitis. A particularly common one is a tight Achilles tendon, the thick band you can feel behind the ankle. Many individuals have a tight Achilles, which directly pulls excessively on the heel bone, causing increased tension on the arch ligament. Thus, one very common recommendation is to stretch this tendon.

Sounds simple, doesn’t it? Yet, the studies show this is an extremely difficult process. Because this is the largest tendon in the body, with the greatest amount of force running through it, the Achilles will lengthen only if subjected to prolonged stretching. The key phrase is ‘sustained tension’, in which the stretch is held for, not just seconds, but many minutes. The research shows, for it to be effective, tension on the Achilles must be held for a total of an hour a day. Yes, you read that correctly. The next question should be “Who is going to do that?” Fortunately, a stretching device was invented which does the work for you, making it much easier to achieve that goal.

Statistically, the most common solution to chronic, recurrent heel pain is the previously-mentioned, custom, prescription foot orthotic. Despite the frequency with which this therapy gets prescribed, the success rate is poor. Yet this is not because orthotics are unable to provide sufficient biomechanical control of foot mechanics to relieve the tension on the infamous plantar fascia. Instead, if improperly prescribed, they cannot be worn comfortably. The task of prescribing and fitting a pair of prescription supports is extremely complex. Many health care providers use inexact or ineffective techniques, or are unfamiliar with the nuances and intricacies of gait mechanics and how best to alter them. Consequently, according to studies, foot orthotics have a poor success rate. Still, when properly prescribed, they continue to be a powerful and reliable method of resolving foot pain.

Sufferers of heel pain are commonly referred to a physical therapist. But “PT” is a broad and multi-faceted practice, and entails more than the performance of just stretching and strengthening exercises. Various technologies are typically applied, all aimed at reducing inflammation (electric stimulation, therapeutic ultrasound, etc). The downside? Physical therapy is time-consuming. But it can be helpful at reducing pain levels.

Historically, when conservative methods provide insufficient relief of heel pain, surgery is recommended. But the evolution of surgical procedures utilized for plantar fasciitis is fascinating, and highlights the trend toward minimizing the trauma produced by all surgical procedures. Decades ago, the entire bottom of the heel was flapped forward, causing tremendous damage. Since the plantar fascia was being tensed excessively, the fascia was cut through, and any spur found there was removed.

It became apparent over the years, removing the extra bone growth had no impact on the amount of relief obtained. Instead, it entailed more trauma than necessary, and the spur is no longer touched by knowledgeable foot surgeons. Regardless, numerous studies revealed an unacceptably high rate of complications when the fascia was cut through. An early modification of the release of the fascia was to only cut the innermost section, which did reduce the rate of complications, but not to adequate levels.

Logically, the plantar fascia is an important structure and has a vital function. Altering it in this fashion, surgically lengthening it, changes how it works. Too often, this method alters foot function, causing various other biomechanical problems. A newer approach entails the removal of diseased tissue from the fascia employing ultrasonic or radiowave energy without cutting through it. These modalities can be applied through tiny incisions minimizing that source of potential complications.

The latest method of treatment, the subject of numerous publications, is a game-changer: extracorporeal shockwave therapy. Being both non-invasive, without negative side effects, and producing an excellent success rate is a powerful combination of characteristics. Generally, three to five treatments provides the desired relief of heel pain, without any down time or recovery period, with lasting improvement. Some of those getting shockwave will still prefer to use their foot orthoses after getting the treatment because of the benefits to their musculoskeletal system, but many will no longer need to. It all depends on the individual because, as you may have heard, we are all different.

In summary, it should be clear by now that foot pain due to a sore heel is not a requirement of modern life. Your feet should not hurt. If simple home measures don’t take care of it, it is likely time to see a specialist. Living with the pain is not an acceptable solution. Chronic discomfort with weight bearing typically leads to changes in gait, eventually resulting in problems from some other area. Just as important, pain when walking will cause the afflicted individual to walk less. This will have ramifications to heart health, circulation, and reduced quality of life. You may need to get help if home remedies don’t take care of your heel pain. But don’t live with foot pain: deal with it. And walk pain-free!

Editor’s note: Dr. Conway McLean is a physician practicing foot and ankle medicine in the Upper Peninsula, with a move of his Marquette office to the downtown area. McLean has lectured internationally on wound care and surgery, being double board certified in surgery, and also in wound care. He has a sub-specialty in foot-ankle orthotics. Dr. McLean welcomes questions or comments atdrcmclean@outlook.com.