08/27/2019    Kevin A. Kirby, DPM

Unusual B/L Heel Pain Case

If a flat-heel sandal (i.e. “zero-drop” shoe) is
improving this patient’s heel pain, then it may
be worth having the patient purchase a pair of
Altra running shoes in order to see how his heel
pain responds. Altra shoes are “zero-drop”
shoes, meaning that the heel and forefoot sole
thicknesses are the same.

Alternatively, the Hoka Bondi shoe, with only a 4
mm heel-drop, but also a 33 mm thickness of soft
foam under the heel may also help resolve the
patient’s pain. This is certainly a relatively
inexpensive and practical method for your patient
to resolve their plantar heel pain.

It is possible that this patient may have had
their heel pain begin from increased compression
forces acting on their plantar heel structures
from ground reaction force (GRF). Factors as
simple as a higher or harder shoe heels can lead
to plantar heel pain in some patients, in my
experience. Nearly all of these patients also
have much more ankle joint dorsiflexion than is
typical (i.e. excessive ankle joint dorsiflexion
compliance) which, I suspect, increases the GRF
on the plantar heel and leads to, basically, a
plantar calcaneal contusion and the plantar
calcaneal pain.

I have also experienced these same symptoms of
sudden onset bilateral plantar heel pain over the
past decade when I wear shoes with normal dress
shoe heel heights (15 mm heel drop or greater).
My trial-and-error solution to eliminate my
plantar heel pain has been to wear shoes with a
lower heel height (i.e. lower heel drop) and with
more heel cushioning.

The correlation of my plantar heel pain to
wearing shoes with higher heel heights has been a
very consistent observation of mine over the past
10 years. I suspect that the gradual degradation
of my plantar heel fat pad with age has been one
of the etiologies of my sensitivity to higher
shoe heel heights. Good luck and please keep us
informed of your patient’s progress.

Kevin A. Kirby, DPM, Sacramento, CA

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08/19/2019    

Unusual B/L Heel Pain Case

First, I would like to make a couple comments
based on my experience with several patients with
similar histories:

1. Note the weight-bearing LAT x-ray is not what
you would expect for a patient that has the foot
structure you describe. There is an elevated 1st
metatarsal, no toe purchase of the hallux and the
cyma line is not broken. When I see an x-ray that
does not support the clinically evaluated foot
structure -I thought (I am retired now) the
patient is off-loading a painful area, in this
case his heel by standing and ambulating bearing
more weight on the lateral border.

2. The patient relates a similar heel pain 9
years ago that did not respond to treatment. I
believe in some of these cases, the heel pain may
never went away and the patient learned to
function with an off-loading compensation gait
strategy.

3. Why did the heel pain come back abruptly? In
my experience it is from a change in shoes or
activity. Maybe 5 months ago, he started wearing
boat type shoes, sandals, started a new exercise
program or even a different job.

Have the patient consult with a PMR to rule out a
radiculopathy. In the meantime start simple with
a goal of trying to reduce the heel pain: low-Dye
strapping (teach pt to do himself), 2x a day ice
massage, stretching 3x day (one leg at a time),
and NSAID, wearing supportive tie shoes and
indoors wear supportive sandals.

If no radiculopathy dx, and if no pain relief
from above after 2 weeks; D/C low Dye and have
the patient apply Lidoderm patches to the plantar
heel at bed time (sometimes you have to think out
of the box). Once the heel pain starts to reduce
the patient then maybe be able to tolerate a pre-
fab orthotic, then over time a CFO.

I found basic heel pain treatments can be
successful, the patient needs to be actively
involved and religious about stretching, icing
and proper shoe protocol.

Ayne Furman, DPM, Alexandria, VA