Case Study September 2016 – Pain From a Heel Spur
Heel Spur – History
On the 14th September 2016, a 47-year-old lady arrived at the clinic complaining of pain from a Heel Spur. She described a stone bruise sensation under her heel that was painful with walking. The Heel Spur triggered intense pain in the early morning or the middle of the night when she got out of bed. The pain was only in the left foot and it had been present for approximately 6 months. She had tried many different treatments to relieve the pain such as gel inserts and rolling her foot on a frozen water bottle. She arrived with X-rays of both feet and a Heel Spur could be clearly seen on the base of the left and right heels. She insisted there was no pain under the right heel, even though the spur was present.
Her GP, who had arranged the X-rays gave her an information sheet on Heel Spur treatment, which also discussed Plantar Fasciitis. This patient, who we will refer to as “Mrs X” was confused. She did not understand the difference between a Heel Spur and Plantar Fasciitis. She was assured there was nothing to worry about, and a full explanation would be given during this initial consultation.
Mrs X boasted good foot health other than this recent setback and she was in good general health too. She took no medications aside from a daily multi vitamin. She was an active lady who played golf and tennis and would walk her dog in a morning before work.
In an attempt to reduce the pain from the Heel Spur, Mrs X had decided to change her walking shoes from an Asics to a Brooks. This made no difference. She often got around in flat shoes, which were not particularly supportive. She wore Hush Puppies and Dianna Ferrari Supersoft, which were described as “comfortable” by the patient. It was explained to Mrs X that comfort was one thing, support was another! Her footwear would need to be addressed.
Physical Assessment for Heel Spur
Even though the Heel Spur was visible on X-ray, the Podiatrist carried out an assessment to determine the area of pain. When pressure was applied to the base of the heel bone, centrally, Mrs X retracted her foot and indicated she was feeling a sharp pain. The pain she was feeling as the pressure was applied was the same as the pain that she would feel when she stood on the heel. Particularly when getting out of bed.
The Podiatrist also palpated the Plantar Fascia around the heel and into the arch of the foot. Mrs X was surprised to find pain in these areas also.
Heel Spur or Plantar Fasciitis?
The Podiatrist informed MRs X that although she did in fact have a Heel Spur, the pain she was feeling was a result of a condition known as Plantar Fasciitis. This is a common condition and a common misconception. And quite understandably. A plantar Heel Spur, which is a small spike of bone under the base of the heel looks terribly sharp, like a rose thorn, so it has been the diagnosis of choice for many years. However, more recently, it is becoming widely accepted that the inflammation and irritation of the Plantar Fascia, that attaches to the base of the heel, is the cause of pain. To support this point, it is worth considering that Mrs X presented with a Heel Spur in her right foot as well as her left, and that the right foot was pain free. This explains why treatments that cushion the heel or deflect pressure away from the Heel Spur rarely resolve the pain. Treatments that are directed at the Plantar Fascia and not the spur are much more reliable.
Other Finding
Mrs X demonstrated extremely tight calf muscles. Something she was not aware of. She did not report cramps or pain in the lower leg area. This tightness in her calf muscles was a major factor in the onset of heel pain, as the muscles will create in increased pulling action on the heel. Most patients that complain of a Heel Spur, or more specifically, Plantar Fasciitis will demonstrate a reduced amount of ankle joint dorsiflexion due to tight calf muscles.
Heel Spur Treatment
As mentioned above, the treatment for this patient was to reduce the load on the Plantar Fascia as opposed to trying to cushion the heel, or deflect pressure away from the Heel Spur. To this end, it was decided to apply rigid sports tape around the affected foot, in order to reduce the spread of the bones. This would reduce the load and tension in the Plantar Fascia, which in turn reduces the pulling sensation at the heel. There is a theory that suggests that the Heel Spur develops due to this pulling action of the Plantar Fascia on the base of the heel.
Mrs X was given a short list of appropriate shoes and the outlets where these shoes could be purchased. She was treated using a Shock Wave Therapy machine which delivered 2000 reps of sound waves, at a maximum of 2 bars of pressure and a speed of 6HZ. She was asked to perform calf stretching daily and was given instructions on how to perform these supinated calf stretches and how often to do them. She was also asked to apply cold ice packs to her feet every evening before bed.
Mrs X returned to the clinic once a week for 6 weeks for repeat applications of Shock Wave Therapy. Her strapping would be changed and her calf range assessed. Each week Mrs X reported less pain from her Heel Spur (Plantar Fasciitis) and her calf range improved. The new shoes became her main shoes and she refrained from her flat and flexible footwear.
Mrs X did not need to have prescription orthotics arranged as she responded well to the support from the rigid sports tape. However, in some cases, where extra support is needed, orthotics are a reliable treatment option. (Please note that the design of the orthotic is crucial to healing, and some prescription orthotics, designed poorly can aggravate the Heel Spur (Plantar Fasciitis) and prolong the condition.
8 Week Follow Up
Mrs X reported that she was now free from pain and could walk quite happily. She was advised that her Heel Spurs would still be present but to not worry as they were not the cause of her pain. She was advised to maintain good calf range and be careful with the use of flat and flexible footwear. Naturally, Mrs X was asked to return to the clinic if her symptoms returned.
PLEASE NOTE: If you have a Heel Spur or if you suffer with Plantar Fasciitis you should seek the help of a Sports Podiatrist. The information in this case study is specific to an individual patient and should not be taken as general advice.
Written by Karl Lockett