Time to discuss a clinical topic Section

Let’s be candid about heel pain – ‘Fat in feet is our friend’

Heel pain is a common problem and my blog this month looks at this briefly. There appears to be no gender variation here, and the age group hovers around 40-65 but peaks at any age where rejuvenation at exercise is attempted. There is a more sinister side to constant heel pain, especially if it grips the patient for more than 4 months. For those who like to see the full dimension of heel pain you can look at my Clinician Portal which can be found under EDUCATION INFORMATION. Over the last year GP practices have been sending more patients with heel pain and some fall into pretty tough categories to fix.

The first sign may be pain on activity or first thing in the morning when rising. If left this worsens. However the patient who works long hours on their feet may experience chronic pain. Jobs requiring over 8 hours standing can turn this into an occupational disorder. Traffic wardens, postal workers, nurses and health care workers, factory workers all fall into this occupational grey zone. Early attention and management can arrest the problem but I am being asked to help people who have had the condition for over a year or more.

Heel pads, insoles and cushioned outersole materials of shoes or boots are helpful but may be short lived. You should use painkillers for no more than 7 days without guidance. Four to six weeks is often the golden window for positive, swift help; beyond this period it can be downhill.

Steroid injections are worthwhile but do go to someone who is experienced and above all qualified with a passion for this condition because treatment can run into months. If you have needle phobia then consider seeking someone who can provide sedation to avoid becoming overly agitated at the time of treatment. If you are offered lots of repeat injections beware – steroid over use will thin out the fat pad. ‘Fat in feet is our friend.’

Stretching – is a good idea to keep the Achilles tendon from tightening. Night splints and simple aids to stretch the fibres can help. Chronic heel pain can become expensive to manage. Our latest approach to long standing heel pain, often called fash-ee-eytis (fasciitis) is ultrasound diagnostics where we measure the thickness of the band as a predictor of outcome.

Injections cost around £50 – £70 in my practise depending upon the complexity and can be done in clinic. Spire Hospital charges around £22 for the drug itself so you are looking at a combined fee of around £72-£92. We are looking at remaining competitive with our non-invasive treatment called extracorporeal shock wave (ECSWT) but success does vary from 45 – 75% with an average of around 58% successful. The hospital will give you an idea of the all-in cost of a course covering three treatments, but ECWST is used after injection treatment. I believe it offers at least another non-operative option.

I find myself using surgery now in 25-30% of the heel pain group as more long-term cases come to seek out solutions.

No longer do we talk about the heel spurs and I certainly do not like the idea of cutting heel spurs out, as it is generally unnecessary. Fasciotomies are small operations that only create a small incision and allow you to walk after a few days. Physiotherapy is important and I work closely with Perform, our own physio brand at Spire, as they understand feet and foot surgery very well and have worked with me for 15 years.

It can take around three months for all pain to settle. There are a plethora of people willing to treat the heel pain and as usual some may promise the earth – ‘We can treat all heel pain,’ Or ‘100% success with such and such a treatment.’ The commercial approach can often over emphasise the success. I might think I am good, and have been in this business for 37 years, but even I don’t achieve a 100%! Of my surgeries I achieve around 88% good satisfaction. Complications are rare but we do audit cases. In a recent audit I found 1 infection, 1 wound that suffered delayed healing, 1 haematoma (localised blood clot) and 3 patients with small sensory loss. This came from a small study cohort of 26 patients. Fifteen had their aims met completely, 1 in part and 2 patients aims were not met. Data was not collected in the remainder of this quick audit over a five year period

Those who return to occupations with a high percentage of standing can deteriorate and the reality is that if this happens your job may need to be considered before embarking on any treatment. I love to help my patients but I cannot compete with the plus 8-hour occupational heel pain problems. The only solution left sometimes is to change or alter the nature of one’s occupation; never an easy task, but then who wants chronic debilitating heel pain forever? There is one hope. For those coming up to retirement, heel pain may clear up so you may want to put off having some types of treatment until you have hung up your office coat and hat. Watch out though, golfers form another group of heel pain sufferers!

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