Orthoses and Balance in the Aging Patient
James McGuire, DPM, Milad Manouche, BA We tend to take
The plantar fascia is a band of connective tissue running from the heel to the ball of the foot. Inflammation of the plantar fascia occurs when this tissue is overstretched. This causes tiny tears to develop, particularly near the insertion site at the heel (at the medial calcaneal tuberosity). When at rest, our body works to mend these tears by tightening and healing itself. This is why plantar fasciitis is often the most painful in the morning. At this time, your body has had the greatest length of rest. Weight bearing again will help the pain to subside. Orthotic management helps via a device that fits tight to the arches. Therefore aiding in stretching out the fascia adequately (but not overstretching it).
One of the inherent consequences of bipedal mobility is the fact that we put immense pressure on the bottom of our feet. Particularly during the heel strike phase of the gait cycle. Anyone who has studied the biomechanics of human movement has learned about the specific forces being applied during walking and upon weight bearing. It will come as no surprise that heel pain is such a prevalent patient complaint.
Our daily sequences of walking and resting is unavoidable. It is what causes the cycle of plantar fascia pain. Plantar fascia is one of the most common diagnoses we see on our incoming prescription forms. It is indeed one of the most common sources of heel pain. Your patient might come into your clinic already claiming to have it. But it is not the only one. There are specific indications that the source of your patient’s pain is something else entirely. A short list of causes would be nerve pain, bursitis, fracture, cysts/tumours, bruising, sciatica, arthritis, and a host of other pathologies. This article serves to present a summary of other causes of heel pain.
Nerve Pain
Unlike plantar fasciitis pain, nerve pain will increase with walking and extended periods of weight bearing (as opposed to rest). Additionally, nerve pain may not be contained only in the foot. It can migrate its way up the body, following the nerve pathway. Nerve pain is caused by compression of a particular nerve, as opposed to the tearing of tissue.
Tarsal Tunnel Pain
A particularly relevant type of nerve pain affecting the heel and foot. Similar to the more common carpal tunnel syndrome, in this case the posterior tibial nerve (or one of its subsidiaries) is compressed as it travels beneath the flexor retinaculum on the medial side of the heel. The pain felt with this syndrome can be felt at the site of compression and can radiate along the nerve path distally to the toes. Compar this to plantar fasciitis pain, which is felt mainly at its insertion site.
Bursitis
A fluid filled sac (bursa) is located at the back of each heel, functioning as a cushion against the bone. Inflammation of one of these sacs can cause heel pain that will increase upon walking or standing (unlike plantar fasciitis). The location of the pain will be toward the posterior aspect of the heel, as opposed to the attachment site of the fascia on the anterior side of the calcaneus. While custom made orthotics are an effective therapy for plantar fasciitis, certain designs can actually cause more pain if the source is bursitis.
Fat Pad Atrophy
This condition generally occurs in overweight and elderly populations, whereas plantar fasciitis is commonly found in all patient populations. The plantar surface of the heel provides cushioning and protection from the consistent pressure exerted on the heel. Deterioration of these fat pads can be quite painful. But, unlike plantar fasciitis, that pain is diffuse across the heel. It is accompanied by an achiness and tenderness. Custom made orthotics can benefit these patients extremely well, particularly accommodative devices with plenty of cushioning.
Heel Fractures
Fractures can usually be pinpointed to a specific injury or trauma, whereas plantar fasciitis tends to develop over time and with general overuse. Fractures need time to rest and heal, after which orthotics may be used to prevent further issue.
Heel Spur
A heel spur is a calcium deposit that develops on the underside of the heel, causing pain and swelling. Heel spurs are actually quite commonly associated with plantar fasciitis. The two may be found together and the pain radiates from the same area on the foot. However, the source of the pain is different in these two conditions. Treatment can be similar for the two, including custom made orthotics, taping and splinting, stretching exercises.
Bone Bruising
A bruise on the heel bone will cause a consistent pain at the point of inflammation, which will dissipate once pressure is taken off of the area. The least amount of pain will be felt first thing in the morning, unlike plantar fasciitis pain. As well, the pain will be felt at the site of the bruise, not related to or necessarily at the attachment site of the plantar fascia. A bone bruise needs time to rest and heal, after which orthotics may be used to prevent further issue.
Cyst
A cyst or tumour on the heel bone is rare, but not unheard of. The weakened bone will be painful, especially when weight bearing and during movement of the foot. Pain will be felt most acutely at the site, not related to or necessarily at the attachment site of the plantar fascia. A painful cyst will require additional treatment, after which orthotics may be used to aid in recovery and prevent further issue.
We’ve spoken about other causes of heel pain. Now let’s look at some signs your patient’s heel pain is not caused by plantar fasciitis:
– Severe and consistent pain- plantar fasciitis is painful and can disrupt your regular activities. However, if the pain is excruciating and debilitating, it is likely something more severe. As well, the pain should subside or at least lessen as the day goes on. If the pain is constant throughout the day or even worsens, look for other causes.
– Pain in other areas of the foot- plantar fasciitis pain is felt most acutely at the insertion site, at the medial tubercle of the calcaneus. This is where the plantar fascia becomes the most stiff when the body begins to rest. Some pain may also be felt along the length of the fascia. If the pain is radiating elsewhere or travelling up the body, look for other causes.
– Visible swelling- plantar fasciitis causes inflammation of the fascia, but you won’t be able to see this with the naked eye, and no swelling will occur. Likely a fracture or sprain is the culprit.
As we’ve seen, there are numerous potential causes for heel pain. Plantar fasciitis has the notable features of its specific pain location, worse symptoms in the morning, and lessening symptoms as the day goes on and with weight bearing. Sometimes patients find it hard to describe accurately the location and type of pain they feel, so making a diagnosis can be easier said than done. That being said, if none of these specific features quite match the complaint, it’s worth broadening the scope of injury.
Paragon’s technical team is always available for advice and to discuss treatment options for your patients. We have the resource of 50 years of orthotic manufacturing experience and a wealth of knowledge at your disposal.
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