Heel tendonitis treatment
by Nathan Wei, MD, FACP, FACR
Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.
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Plantar heel pain (pain in the bottom of the heel) is the most common type of heel pain.
The most common cause of plantar heel pain is stress on the plantar fascia. While the plantar fascia is not strictly a tendon (it does not connect a muscle to bone), it behaves as a tendon since they connect the base of the toes to the heel and consist of fibrous bands that support the arch of the foot. Pain is derived from both tension on the insertion point at the heel as well as from localized nerve entrapment of the medial calcaneal branch of the lateral plantar nerve.
Patients present with isolated plantar heel pain upon weight-bearing, either in the morning when waking up or after sitting for a period of rest. The pain tends to decrease after a few minutes, then returns as the day proceeds. Associated conditions include obesity, tightness of the Achilles tendon, and inappropriate shoe wear.
Following physical examination, diagnostic ultrasound or magnetic resonance imaging can confirm the diagnosis.
Initial treatment options may include non-steroidal anti-inflammatory drugs (NSAIDs), padding and strapping of the foot, and corticosteroid injections. The latter should be used sparingly- no more than two! And the injections need to be ultrasound guided.
Patient instructions can include regular stretching of the calf muscles, avoidance of flat shoes (such as flip-flops)and barefoot walking, use of ice on the affected part, arch supports and heel cushions, and limitation of excessive physical activities.
Patients usually get better within 6 weeks of start of treatment. If improvement is noted, the initial therapy program is continued until symptoms are resolved.
Patients who have not responded to earlier therapies may be treated with custom orthotic devices, night splints to stretch the plantar fascia during sleep, and cast immobilization for 4 to 6 weeks.
Obese patients must lose weight.
For patients who fail the above, ultrasound-guided percutaneous needle tenotomy with platelet-rich plasma or extracorporeal shock wave therapy may be considered.
Following the program as outlined above, 90% to 95% of patients will improve within 1 year. A subset of patients will have continued problems.
The posterior heel (back of the heel) is the second most common location of heel tendon issues.
Achilles tendonitis is a misnomer. The preferred term is "tendinopathy." The reason is that the Achilles tendon is inflamed only early on in its course. With chronicity, comes tendon fiber disruption and wear and tear.
There are two large muscles in the calf, the gastrocnemius and soleus. These muscles generate the power for pushing off with the foot or standing up on the toes. The Achilles tendon connects these muscles to the heel.
This tendon can become injured, most commonly as a result of overuse or arthritis, although injury can also be associated with trauma.
Tendinopathy due to overuse is most common in younger individuals and can occur in walkers, runners, or other athletes, especially in sports like basketball that involve jumping. Jumping places a large amount of stress on the Achilles tendon.
Tendinopathy can also develop in the middle aged and elderly population.
Symptoms usually include pain in the affected heel when walking or running. The tendon is usually painful to touch and the skin over the tendon may be swollen and warm.
Achilles tendinopathy may predispose the patient to Achilles tendon rupture. Patients who experience this usually describe the injury as a sharp pain, like someone hit them in the back of the heel with a baseball bat.
Imaging studies can also be helpful. Diagnostic ultrasound or MRI will demonstrate inflammation in the tendon.
The initial treatment for Achilles tendonitis is usually non-steroidal anti-inflammatory drugs (NSAIDs) and physical therapy to stretch the muscle-tendon unit and strengthen the muscles of the calf. In addition, any activity that aggravates symptoms need to be limited. Occasionally, casting is used to immobilize the heel and allow the inflammation to quiet down.
Recently, a new procedure called percutaneous needle tenotomy and autologous tissue grafting has been used and is highly successful. It often prevents the need for surgery. With this procedure, a small needle is inserted using ultrasound needle guidance and local anesthetic. The needle is used to punch a series of small holes in the tendon and irritate it. This procedure initiates a low grade inflammatory response. Platelet rich plasma obtained from a sample of the patient's whole blood is then injected into the area. Platelets are cells that are rich in healing and growth factors. The platelet rich plasma then stimulates the growth of healthy tendon tissue.
Conservative therapy is usually successful in improving symptoms, although they may recur if the offending activity is not limited or if the strength and flexibility of the tendon is not continued.
Prevention is very important. Maintaining strength and flexibility in the muscles of the calf will help reduce the risk of tendinopathy. Overuse of a weak or tight Achilles tendon is a set-up for tendinitis.
The worst complication is tearing of the tendon. In this case surgical repair is necessary, but made more difficult because the tendon is not normal.
Posterior tibial tendonopathy is a strain placed on the posterior tibial tendon. The posterior tibial tendon runs along the inside of the ankle and the foot. When there is posterior tibial tendon dysfunction, the tendon does not elevate the arch, resulting in flat feet. This can lead to heel pain, arch pain, plantar fasciitis and/or heel spurs. With posterior tibial tendonopathy, pain will be more severe upon weight bearing, especially while walking or running.
Years of over-pronation (flat feet) can also lead to posterior tibial tendon dysfunction. At first the pain or swelling may be intermittent, but eventually the problem may become more permanent.
Limiting activity to control the pain and swelling is ther first step in treatment.
Conservative treatments include wearing orthotics with rearfoot posting and longitudinal arch support to reduce strain on the posterior tibial tendon and prevent excessive stretching of the plantar fascia. The orthotic should also be designed with materials to absorb shock.
Vary exercise routines. The variety will keep one set of muscles from being under continuous stress.
Posterior tibial tendinopathy is also responsive to ultrasound-guided percutaneous needle tenotomy with platelet-rich plasma.
For more information on heel tendonitis and on other forms of tendonitis, please visit our sister site:
Tendonitis and PRP Tendonitis and PRP.com provides reliable, accurate, and useful information on tendonitis treatment written by a board-certified rheumatologist. Learn more about how to get tendonitis relief using the most up-to-date methods.
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