Conditions of the Foot
by Dr. Mark H. Tompkins

Heel Pain

Heel Spur Syndrome (HSS), heel spurs, plantar fasciitis, heel bursitis all refer to the same condition- typical heel pain ; and is third only to headaches and low back pain as the most common cause of inflammatory pain in the human body.

HSS is characterized by pain after periods of inactivity (especially in the morning). It usually improves with normal activity, and gets worse again at the end of an active day. As the condition worsens, gait alterations usually lead to pain in other areas of the feet, knees, hips, or back.

Appropriate treatment for HSS is dependent on the certainty of the diagnosis. There are other causes of heel pain that must be eliminated prior to successful treatment. If treated properly (and thoroughly) typical heel pain, or HSS, responds to conservative treatment in over 80% of patients. Conservative treatment consists of a combination of injection therapy, oral anti-inflammatory medications (NSAIDS), inserts, physical therapy, shoe modification and rigorous stretching.

My initial treatment regimen for mild cases of HSS, is over-the-counter (OTC) inserts and anti-inflammatory medications, rigorous stretching exercises, and shoe modification.

Resistant mild cases and moderate to severe cases of HSS are treated with a combination of corticosteroid injections; prescription strength NSAIDS; prescription inserts-biomechanical functional orthotics (BFO); rigorous stretching exercises; shoe modification; and physical therapy. The level and extent of treatment is based upon individual patient response. Many patients respond very quickly to limited treatment, while others need continued and aggressive attention. It is important to recognize this fact, as successful conservative treatment can take up to 4-6 months, or longer!

Chronic-unresponsive HSS is characterized by persistent pain for at least six months duration, AND has been resistant to the above noted conservative treatments, AND is altering the patients gait (walking) pattern. Less than 10% of patients who experience HSS symptoms develop this degree and level of pain/disability. Unfortunately, this still represents a significant number of people, as estimates range in the 6-7 million as the number of people affected by HSS yearly.

A variety of options are available to patients who suffer from chronic-unresponsive HSS. The question is what, if any, further treatment is warranted? In my professional opinion, if an individual's gait (walking) pattern is being altered significantly , further treatment is not only warranted, but also medically necessary. The definition of significantly being, that which is causing the patient to transfer weight abnormally, i.e. limping to any degree, walking more on one side of the foot or another, or shortening/lengthening stride-length or pace. These alterations not only lead to further foot pathology, but increase the incidence of knee, hip, or back problems, AND should be treated.

Options range from non-invasive, to minimally invasive, to invasive treatments/procedures. It is important to recognize that the NUMBER ONE COMPLICATION in treating HSS is RECURRENT HEEL PAIN! No matter what medication, shot, insert, therapy, or 'procedure'; some people will continue to live with heel pain in spite of exhaustive treatment. However, the success rate of these 'procedures' ranges from 70-90%, and in most cases result in complete and permanent pain relief.

The only FDA-approved non-invasive procedure available in the U.S. today is extra-corporeal shockwave therapy (ESWT), or orthotripsy. Please see below for more information regarding this new and exciting treatment. It should be emphasized again, this treatment alternative is indicated ONLY for patients who have had pain for at least six months, AND have been resistant to the aforementioned exhaustive conservative treatments. No long-term studies are available in the U.S. to determine the complete effectiveness of this treatment, but statistics available from Europe reveal a 70-90 % success rate. Third-party payers in the U.S. have been relatively reluctant to universally accept this form of treatment of chronic-unresponsive HSS. Coverage to this date (5/1/2001) has been on an individual patient basis and pre-certification is mandatory! I am trained, certified, and have significant experience in performing ESWT treatments.

In my professional opinion, ESWT exists as a viable alternative to patients who meet the strict criteria of failed conservative treatment set forth by the American College of Foot and Ankle Surgeons, and whose personal and/or professional commitments prevent, or limit, them from having traditional minimally-invasive, or invasive surgical procedures.

Minimally invasive procedures involve varying methods of elongating or detaching plantar-fascial structure(s) through limited, or small incisions in the foot. Controversy exists regarding the effectiveness of these procedures, however, a significant % of patient's symptoms are relieved with this level of treatment. There is ample documentation in the current world literature to support this level of treatment, IF performed properly. I am trained, certified, and have significant experience in performing a number of minimally invasive procedures.

In my professional opinion, minimally-invasive procedure(s) exists as a viable alternative to patients who meet the strict criteria of failed conservative treatment set forth by the American College of Foot and Ankle Surgeons, and whose personal and/or professional commitments prevent, or limit, them from having traditional invasive surgical procedures.

Invasive surgical procedures involve varying methods of elongating/detaching/resecting plantar-fascial structures; removing/resecting/altering plantar heel spurs; removing or excising various soft tissue structures/masses; and releasing/removing various nerve structure(s). Again there is considerable controversy as to 'the best' surgical approach and procedure. There is ample documentation in the current world literature to support these various techniques. The technique I utilize in my practice involves a procedure that is done on an outpatient basis under a twilight/local anesthesia. I advocate resecting a portion of the insertional area of the plantar fascia, with resection of the spur, and removal of any soft tissue pathology that may be present. Healing times vary with individual patients but ranges from 6-8 weeks in a special surgical shoe. The success rate is in the vicinity of 80-90%, but total healing time (some continued pain and swelling) can be lengthy for some patients.

In my professional opinion, invasive surgical procedures exist as a viable alternative to patients who meet the strict criteria of failed conservative treatment set forth by The American College of Foot and Ankle Surgeons. I am trained, certified, and have significant experience in performing invasive surgical procedures.

In summary, successful treatment of typical heel pain (HSS) is dependent on the certainty of the diagnosis and thorough conservative management prior to any attempted non-invasive or invasive procedures. The vast majority of people who develop HSS, improve by simply wearing more supportive shoes, buying an over-the-counter (OTC) heel cup or arch support, and/or taking aspirin-type medications. Individuals, who continue to experience pain, should be seen by a foot professional to prevent further problems from arising.

Conditions of the Foot by Dr. Mark H. Tompkins

Heel Pain

Conditions of the Foot
by Dr. Mark H. Tompkins