By Dr. Steven Gershman
If you had a headache as the major symptom of brain cancer, would you want to just treat the headache? You may get rid of the headache, but the cancer would continue its course. If you had a broken bone causing pain, would you just take pain pills to relieve the pain and not stabilize and set the broken bone? In other words, is treating the symptom of a problem and not getting to the underlying cause the proper way to manage the issue? As a doctor I deal with this every day. Do I treat just the symptom, or do I go after the underlying cause? When dealing with heel pain do I just treat the pain or do I look at what is causing it and manage that and then treat any pain that is still remaining after that?
Types of heel pain
In general, there are three main types of heel pain based on causes.
- 1. Nerve pain: generally, affects he bottom of the heel. It usually hurts when first getting up then can ease up for a while after being on it, then often gets worse later after some time on the foot.
- 2. Bone spur pain: can affect the bottom and back of the heel and can hurt anytime when on the feet standing or walking.
- 3. Connective tissue (fascia) pain: mainly affects the bottom of the heel although the achilles tendon on the back of the heel can be involved with back of heel pain. It can occur at night when off the foot, in addition to weight bearing during the day.
To understand heel spur pain, I highly recommend reading my blog "Heel Spurs: Symptoms, Causes, And Treatment" as it gives a good foundation on understanding heel pain and treatment.
Heel spurs on the posterior or back of the heel are quite painful, while spurs on the plantar or bottom of the heel often are asymptomatic. Heel pain on the bottom of the heel is often connective tissue, at the plantar fascia or the muscle just above it called the abductor hallucis. The other common cause of plantar heel pain is a nerve entrapment at the medial or inside of the heel.
What do ALL these types of heel pain have in common besides pain?
They all have a cause and that cause is usually some mechanical or structural flaw in the lower extremity. Yes, there are some types of diseases like Rheumatoid Arthritis, Gout and Diabetes that can cause heel pain, but the vast majority of cases are structural/mechanical (biomechanical) flaws. These flaws lead to some type of abnormal forces on the foot causing damage and then pain. Over time these biomechanical flaws cause permanent changes in the anatomy of the feet which further adds to the initial flaws causing more pain.
It is beyond the scope of this blog to explain all the various types of biomechanical issues that cause heel pain. In general, over pronation and hypermobility (too much motion) is often the result of the biomechanical defects. Over pronation can cause numerous problems damaging the feet. For example, over pronation causes overuse of the calf muscles which torque on the achilles tendon and can lead to posterior heel spurs. Over pronation can stretch the plantar fascia as the foot drops the arch and elongates. This stretching can cause micro tears in the fascia and inflammation and pain. Nerve entrapments can also occur from abnormal foot motion caused by faulty biomechanics resulting in severe pain. Under pronation from rigid feet can cause heel bone pain from direct impact on the floor day after day.
Heel pain diagnosis and treatment
So when a patient presents to my office with any type of heel pain, I do not just treat the symptoms. There are some practitioners who like to "cookbook" their treatment. For example, they get a diagnosis of "plantar fasciitis" and just use the same protocol regardless of the underlying cause. They may use cortisone injections in all these cases or oral medications or simple exercises. These all can alleviate the pain, BUT the underlying cause is still present and in time will rear its head again and can be worse from the ongoing damage that is still evolving.
In my approach, and with 32 years’ experience doing it successfully, after I reach an initial diagnosis of the presenting problem, I then look at the structure and biomechanics of the lower extremity. This gives me a secondary diagnosis, "what caused the primary problem”? With that secondary diagnosis I can treat the underlying cause and usually the symptoms will improve. I do have the option of adding symptom relief at any time in if the pain is severe or slow to resolve.
One example of this method of treatment is the patient presenting with plantar fasciitis caused by over pronation. Over time over pronation if left unchecked can cause joint damage and arthritis, bone spurs, deformed toes and knee and back pain. By just treating the pain of fasciitis, none of this is addressed and can continue its insidious course. So how are biomechanical/structural issues treated? Well, that is the topic of this blog, shoe inserts.
Shoe inserts for heel pain
Although surgery can correct some structural defects in the feet, most biomechanic/structure defects are not amenable to surgery. Patients ask, where does this biomechanical or structural problem come from? Most often it is congenital or genetic. Basically "you are born with it”.
Mechanical/structural issues require mechanical therapy. I tell my patients it’s like glasses for the eyes. You don't change the eyes with glasses, but by wearing them the eyes work normally and vision is restored to correct levels. Shoe inserts and true orthotics work for the feet like glasses to the eyes. The correct shoe insert for heel pain can not only reduce or alleviate the pain, but also correct the underlying mechanical issues while wearing them. Function is improved, so that pain will resolve.
A well-made insert is not just an "arch support”. The best shoe inserts for heel pain can also stabilize the foot and improve gait. All this can reduce pronation and guide the foot into its proper alignment and function while it improves the gait.
- • The heel cup reduces pathological heel motion that is a component of over pronation.
- • If there is a gel pad in the heel as in the Orthofeet Biosole gel orthotic that I use frequently, it protects and cushions the sensitive heel bone itself. It has a trampoline effect that disperses shock forces from the bottom of the heel.
- • The firm plate supports the arch and the midfoot and the extension beyond it cushions the metatarsal heads and toes.
Insoles with the features described above are designed by Orthofeet, an orthopedic footwear brand that is dedicated to helping people with various foot conditions and foot problems. All their insoles and shoes are biomechanically designed to promote proper foot and body alignment from the ground up. To view the collection of insoles for heel pain click here.
With heel pain after I diagnose the underlying cause, if it is biomechanical/structural, I will often start with a non-custom insert unless it is clear the problem is so severe or the structure is so pathological that a true custom orthotic insole is required. I can test the non-custom insert immediately on the floor first and if it fits well and reduces the pronation on the floor, I test it in the shoe and have the patient walk. This way a decision can be made whether to start with this device or go to another or true custom device. The device I use most often as an initial treatment for heel pain caused by biomechanical/structural issues is the Orthofeet Biosole Gel Sport. I have used this device for over 25 years quite successfully in heel pain cases and other types pain. It offers good pronation/motion control, arch support, and cushioning.
I do medical treatment for heel pain generally AFTER I dispense the non-custom orthotic insole. In severe pain I might add the medication or injection at the same time but prefer to wait at least 2 weeks to see how the patient responds to just the insert. Oral medication or cortisone injections help with the symptoms but DON"T deal at all with the cause. I want to see long term results, not a quick fix. I have been in practice 32 years and work in a small city where I can follow patients for years.
Shoes for heel pain
Another part of the treatment is shoes for heel pain or any other pain issue. Footwear is a critical part of the treatment. An orthotic or insole only works as well as the shoe it fits in. On the first visit I have patients bring in ALL their shoes or at least all the various types. I look for wear, proper fit and whether the shoe is appropriate for the patient's feet and for an insert. Many patients have pain simply because of worn out or improper shoes.
The best shoes for heel pain should be designed with the following features:
- 1. Proper shoes must have a removable insert that can be removed and replaced by the new insert or orthotic. If there isn't enough room inside the shoe, treatment will fail.
- 2. Extra depth shoes like many of the Orthofeet shoes are especially helpful and allow room for the insert and any modifications necessary.
- 3. Width is another big issue I see in the office. Many patients wear shoes too narrow or too pointed in the toe box which makes it difficult to add inserts and cause pain themselves as they damage the feet. Tight narrow shoes can alter the biomechanics making it more difficult to treat heel pain. Unfortunately, many footwear companies only design one width but if you look to more specialized brands such as Orthofeet, you will find extended widths up to 6E (extra extra wide).
- 4. Shoes must also be stiff enough to control foot motion in concert with the insert. Soft poorly made shoes are simply not strong enough to alter the gait and biomechanics. If the shoe can be easily bent just ahead of the heel, it is too soft.
- 5. A minimal heel to toe drop (height difference between the front and back of the shoe) is recommended as it transfers the weight from the heel to the front of the foot, relieving pressure on the heel.
- 6. Ergonomic sole design with mild rocker bottom propels the foot forward and facilitates foot motion which helps relieve heel pain.
I wear Orthofeet shoes myself with orthotics to deal with severe over pronation and hypermobility. They are the most comfortable shoes I have ever worn. They provide pain relief and comfort but most importantly are able to correct the biomechanical issues that are related to heel pain. Click here to view Orthofeet heel pain shoes for men and women.
Finally, if you have heel pain, talk to your provider and question WHY! Ask and find out what the real cause is. If the medical provider isn't interested to find out or explain it to you, go elsewhere. You deserve to have the whole picture diagnosed so that you aren't going to only have symptom removal. Your feet and possibly your knees and back will thank you later. Also, if you are provided an insert, it needs to be comfortable so you can wear it all the time. Like glasses, it only works while you wear it. Be patient as inserts can take time to allow healing and resolve pain. Unlike quick fixes, the pain relief afforded is long term.