Assist heel pain patients by providing the necessary advice, care, and support services

Society has recognized the need to be more active. The sedentary lifestyle that became the hallmark of the North American adult is gradually being replaced by a more dynamic approach. Wellness is the rallying point of the new consciousness, and fitness plays a leading role in the wellness movement.

As people move from inactive postures, their underused joints are exposed to new and potentially damaging stresses. One of the most common complaints is heel and foot pain. The shift toward walking, running, and active sports can put new strain patterns into the foot and its arches. The heel is particularly susceptible to damaging tension, as it is the structure that bears significant weight and also acts as an anchor for the attachment of large tendons and fascia.

Chiropractors need to be especially aware of the implications of continual heel pain. The posture of the individual, as well as the initiation of movement, begins with the foot striking the ground. Heels are the first contact point in the gait cycle, so a painful heel can have a dramatic effect on the posture and movements of the entire body.

The calcaneus is the largest of the 33 foot bones shaped to allow transitional forces to be distributed throughout the support structure. On the plantar surface of the calcaneus, there is a broad attachment of the plantar fascia; and on the posterior surface, the large Achilles tendon is anchored. These two strong and broad tendinous fascial attachments are a common source of heel pain. This sometimes disabling pain can be located in the front, bottom, or back of the heel. There are two distinct causes of the painful heel: faulty biomechanics and, occasionally, diseases that affect the heel.

Cooling Your Heels

The posture of the foot is mostly set by the age of 7, which means that a child who exhibits excessive pronation at an early age is a candidate for progressive changes in the biomechanics of the foot and the rest of the kinetic chain. These ongoing postural changes affect the ligamentous and fascial structures that attach to the heel. Eventually, overpronation and plantar fascial stretching occur. This is mostly a silent process until the constant pull on soft tissues erupts in an inflammatory reaction. Common triggers to this event can be new and aggressive activity levels, increased weight gain, and poor muscle tone in the lower limbs.

Plantar fasciitis is a result of overstretching of the plantar fascia, a deep tensile band that runs from the front of the calcaneus and inserts into the ball of the foot. This dense strip of connective tissue is strung across the medial longitudinal arch and acts like the string on a bow. In a typical foot, the arch and the fascia flatten during walking. The stiff band stabilizes the bones of the foot, and there is an effortless exchange of kinetic movement. People who have standing or walking occupations are more prone to this problem. Excessive exercise and poor-fitting athletic shoes exacerbate the fasciitis. Pregnant women are candidates for heel pain because of the increased weight and hormonally induced ligamentous laxity.

As the calcaneus inverts in an overpronated foot, the plantar fascia is continuously stretched and the foot begins to lose its inherent stability. The faulty foot posture and overstretching lead to muscle tears and bone spurs. Palpatory pain is easily elicited with heel spurs. Firm pressure in the center of the heel or along the anterior border of the calcaneus can cause an extreme, needle-like pain, which is usually indicative of an emerging spur. Pain along the posterior calcaneus border can be associated with spurring in the Achilles tendon insertion point. In both cases, an x-ray can disclose well-formed spurs.

Constant pounding from walking, running, or weight gain tears at the lining of the membrane that covers the heel bone. A persistent bursitis or periostitis can mimic heel spur pain. The classic symptom profile for a heel spur sufferer is poststatic dyskinesia, the term used to describe “pain after rest.” This heel pain is experienced in the early morning and subsides as the day progresses. In the morning, the muscles are tight and unforgiving in their flexibility. As the day progresses, the muscles lengthen and the pain subsides.

Between the ages of 8 and 13, children become increasingly active. Jumping and running can inflame the growth centers of the heels. On radiographs, there can be increased density and fragmentation. The condition is called Sever’s disease and was originally believed to be one of the osteochondroses but is now believed to be a traction injury of the Achilles tendon.1 This confirms the need to assess pediatric biomechanics. With proper care and support, this problem can disappear and is not likely to recur.

Although heel pain is mostly from biomechanical origins, other disease states should be considered. The chiropractor must be aware of rheumatoid arthritis, which has a predilection for the heel, as well as gout and other arthritides. A more commonly seen condition is known as “pump bump.” In the area where the Achilles tendon attaches to the heel, a bony enlargement known as Haglund’s deformity can exist. The constant rubbing and friction of poor shoe fit can inflame a bursa at this attachment point. Again, faulty foot posture and shoe sizing affect the incidence of heel pain.

Achilles tendonitis is a troublesome and painful situation. Inflammation of the tendon as it inserts on the back surface of the heel bone occurs in people who walk and run with tightened calf muscles. In time, a bony spur may form in this tendon, which is further aggravated by an active lifestyle.

Well Healed

The solution to heel pain is both prevention and timely management. Only after all conservative measures have been exhausted should a patient consider pharmaceutical or surgical interventions. With an extensive understanding of the interrelated biomechanics and skill to assess and adjust the foot, DCs can give proper care to their patients.

Prevention. This begins with a thorough assessment and screening of the foot posture. A patient’s foot and ankle can easily be evaluated as part of an entry examination. Observation of the foot in standing posture can reveal excessive pronation or other deformities. A simple navicular drop test can confirm the instability of the longitudinal arch and at the same time alert the patient to the unseen dangers of overpronation. Palpation of the foot undersurface may detect a tightened plantar fascia. Deeper palpation of the calcaneal region can determine if heel spurs or Achilles tendonitis is present. Simply asking the patients if painful heels trouble them in the morning can assist in the decision-making. Finally, standard x-rays of the foot can be taken if there is enough suspicion that a spur or other pathology may exist.

A special emphasis can be placed on children’s posture. Parents need to become aware of the damaging, long-term consequences of unsupported arches. Heel pain is a perfect example for the parents to understand the benefits of a preventive approach to health care.

Orthotics. Because the majority of heel pain is related to faulty biomechanics, chiropractors are well aware of the advantage of neurologically competent joints. Care for any peripheral disorder is adjunctive to detection of vertebral subluxations that interfere with the normal function. Custom orthotics are also a natural choice in the chiropractic paradigm of care. These devices control excessive pronation and support the ligaments and tendons that attach to the heel bone. They also can be a preventative tool in the long-term management of damaged heels.

Orthotics will also be used to arrest the overpronation in the gait cycle. Medial wedging at the rearfoot and posting of the orthotic in more extreme cases can limit the excursion of the foot. Providing midstance support takes a tremendous load off the damaged tissues. Maintaining a flexible foot while providing cushioning and support are the goals of orthotic placement in a patient with heel pain.

Exercise. This can be an enormous benefit in painful heel management. Exercises are necessary to restore strength and integrity to the system. Passive stretching of the Achilles tendon and calf muscles is the prime exercise. Toe-walking and heel raises are ideal to stretch and strengthen the affected area.

Unfortunately, heel pain is a common occurrence in an active lifestyle, but chiropractors can provide natural solutions that work. CP

David S. Fletcher, DC, FCCSS (C), a Fellow of the College of Chiropractic Sport Sciences (Canada), has been in private practice for 22 years at The Fletcher Clinic, Pickering, Toronto, Canada. He is recognized internationally for blending traditional chiropractic principles with contemporary technologies and strategies. Fletcher can be reached at 905-831-9696; fletch5@rogers.com;   www.chiroacademy.com.

Reference

1. McRae R. Clinical Orthopedic Examination. 2nd ed. New York: Churchill Livingstone; 1986:175.