January 7, 2019 by Robert M. Conenello, DPM, FACFAS
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.
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 killingme. 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
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.
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