“The most common cause is plantar fasciitis”

Prof. Dr. med. Markus Walther from Schoen Clinic in Munich-Harlaching, Germany, explains how symptoms associated with heel spurs can be treated successfully and which other conditions can trigger chronic heel and ankle pain.

life: How can the indication of chronic heel and ankle pain be seen from an epidemiological perspective?

Prof. Walther: At our clinic, patients with heel and ankle problems account for about ten to twenty percent. But that can’t be applied to the general population. Most are treated by office-based orthopedists and only come to us when standard conservative treatment options aren’t helping.

What are the most common diagnoses?

Prof. Walther: The main culprit is plantar fasciitis. But Haglund’s deformity, meaning insertional tendinopathy of the Achilles tendon, is also common. This is commonly known as heel spur or pump bump.

What exactly is plantar fasciitis, and who is affected most often?

Prof. Walther: In the case of plantar fasciitis, the large band of connective tissue (plantar fascia) in the sole of the foot becomes chronically inflamed at the site where it inserts into the heel bone. This is what causes pain, and not the bony spur which can be seen on the X-ray image. That is only a secondary aspect of this condition. Problems usually manifest from middle-age onward because the fascia loses elasticity. Risk factors include obesity and a sedentary lifestyle. Foot misalignments, such as high-arched foot or flat foot also support the development of plantar fasciitis.

How can the inflamed structures be relieved?

Prof. Walther: Conservative management is effective for 95 to 98 percent of patients, with foot orthoses as first-line treatment. Shock-absorbing foot orthoses reduce pressure exerted on the painful area and correct the foot misalignment. Adding a relief bridge along the length of the fascia is a good idea because it relaxes the entire plantar fascia. In addition to foot orthoses, stretching is important to counteract the shortening of the dorsal chain. We recommend exercises that can be carried out at home.

What new treatment methods are there?

Prof. Walther: Evidence suggests that shockwave treatment is effective, but also therapeutic X-ray radiation in cases of a high level of inflammation. However, this is recommended only for people aged 40 and over. Cortisone injections have become controversial because of their negative effects on the tissue structure. Botox, however, has a success rate of about 60 to 70 percent. In many cases, one fan-shaped injection into the painful area is sufficient as it relaxes the plantar structures and reduces pain. If conservative methods aren’t working, minimally invasive procedures are now also performed. The principle is to sever the plantar fascia’s contracted fibers, which reduces tension and aids healing. A bony heel spur is usually removed at the same time.

In cases of Haglund’s deformity, the bony edges where the Achilles tendon inserts into the bone are removed because they’re causing chronic irritation and inflammation. The minimally invasive osteotomy to change the positioning of the heel bone is relatively new. This surgical procedure turns the irritating bony edges away from the Achilles tendon and lengthens the Achilles tendon by a few millimeters at the same time. This procedure is particularly useful for patients suffering from shortened calf muscles. The problem is completely resolved by what is known as Zadek Osteotomy.

What treatment duration do you recommend?

Prof. Walther: There are no specific time guidelines for non-surgical treatment. For as long as the symptoms are reducing, treatment should be continued, even if it takes many months in some cases until a patient is completely free from problems. But the symptoms don’t usually return in that case. After surgery, patients should wear heel cushions and foot orthoses for three to four months. Putting strain on the Achilles tendon too quickly can delay healing. Recent studies have shown that, in addition to obesity, impaired post-operative wound healing can be responsible for recurring calcification. After surgery, we therefore recommend subjecting the foot to only very little strain for a few weeks to allow the tendon insertion to regenerate.



What other conditions can cause chronic heel and ankle pain?

Prof. Walther: DA clinical examination usually provides important indicators as to what the problem might be. Pain caused by pressure on the sole of the foot where the plantar fascia inserts into the bone is characteristic of plantar fasciitis. If lateral pressure on the heel is painful, it could be an indication of a stress fracture, meaning broken bones caused by an imbalance of strain on the bones and bone strength. If there is no obvious excessive strain, we first have to find the reason for the potentially reduced bone mineral density. The first step is to reduce strain. Bone strength can also be supported by taking osteoporosis medication. In these cases, it may make sense to refer the patient to an osteologist.

Pain not related to strain, for example at night, may indicate inflammation or bone tumors. With chronic heel and ankle pain on both sides, rheumatism should be considered in particular. An inflamed nerve, on the other hand, can cause symptoms very similar to heel spurs. Cases usually show no pathological findings on the MRI scan of the plantar fascia and don’t respond to heel spur treatment. The MRI sometimes reveals abnormalities in the muscles, such as denervation edema caused by damaged nerves (see illustration). These abnormalities seen on the MRI scan are often visible before a neurologist can confirm nerve damage using measurements.

Depending on the extent of the nerve compression, conservative treatment using pain medication and physiotherapy can be attempted. In individual cases, nerve decompression surgery may be indicated, similar to that of carpal tunnel syndrome.

Generally, the following applies: plantar fasciitis is by far the most common cause of chronic heel and ankle pain, and it is usually associated with a characteristic medical history and examination results. However, if standard treatment options aren’t working after six to eight weeks, imaging using an MRI will be required.

Noticeable relief for chronic heel and ankle pain

The soft ­ViscoSpot heel cushion helps in cases of acute heel and ankle pain, specifically with heel spurs and tarsal bone pain. Three zones made of material with varying firmness offer targeted relief: the innermost zone is the white spot – a particularly soft zone that absorbs pressure at the root of the pain. The blue zone around the white spot is somewhat firmer and relieves the insertion of the plantar fascia, while hollowing the fascia pathway. This allows inflammations and irritations to subside faster. The firm gray zone around the outer edge gently guides the hindfoot at every step and softly supports it during heel-to-toe movements. The viscoelastic heel cushion offers an anatomical fit and optimally adapts to the shape of the foot and shoe.

The ErgoPad redux heel foot orthosis provides relief in cases of chronic heel and ankle pain, plantar fasciitis and plantar heel spurs. The inner synthetic core with ReliefCore Technology targets painful areas. There is a recess under the heel bone to reduce pressure when the foot is put down. The unique fan design relaxes the plantar aponeurosis, which can cause pain as a result of inflammatory changes. The double-layered padding additionally cushions the heel. The ErgoPad redux heel foot orthosis also supports the decreased longitudinal arch, thus sustainably counteracting chronic heel and ankle pain.



Images: Bauerfeind, Conny Kurz, Radiologie in München Harlaching