Our feet can handle a lot of stress, but if you put too much of a load on them, it can, over time, cause damage. When heel pain begins to limit your daily activities, it may be time to see a podiatrist to asses your issue.
Dr. Ian Aveytua discusses some of the most common causes of heel pain and the treatment options available at Memorial Health System.
Selected Podcast
Do You Suffer From Undiagnosed Heel Pain?
Featured Speaker:
Ian Aveytua, DPM
Ian Aveytua, DPM is a podiatrist with Memorial Health System, recently joining in July of 2018. He completed his three year residency in podiatric medicine and surgery at Mount Sinai Beth Israel in New York, New York. He received his medical degree from The New York College of Podiatric Medicine in New York, New York. Transcription:
Do You Suffer From Undiagnosed Heel Pain?
Melanie Cole (Host): You know our feet can handle a lot of stress, but if you put too much of a load on them; it can, over time, cause damage. When heel pain begins to limit your daily activities, it might be time to see a podiatrist to assess your issue. My guest today is Dr. Ian Aveytua. He’s a podiatrist with Memorial Health System. Dr. Aveytua what are some of the most common causes of heel pain that you see every day?
Ian Aveytua, DPM (Guest): Some of the most common heel pain patients that come into our office usually have plantar fasciitis, probably number one. And then another one that’s pretty common that can be assessed is tarsal tunnel syndrome or nerve impingement and then even a bursitis that could be causing some pain for a lot of patients.
Melanie: Dr. Aveytua before we talk about diagnosis of some of these issues; please answer this common question that listeners might have. Why would they go see a podiatrist or why would they go see an orthopedic surgeon when they have foot problems? Please explain why what you do as a specialist in the feet is the reason to see a podiatrist.
Dr. Aveytua: Yeah, so both podiatrists and orthopedists do a lot of the same work. Orthopedists depending on what their specialty is will range, do special fellowship training or surgery for the whole body and sometimes they may do a lot of cases in the foot or ankle and sometimes they may not. They may just know the body in general. With podiatrists, the first two years of medical school or podiatry school are with a lot them are the same classes as medical school and then the last two years kind of start to focus in and hone in on the foot and ankle. And then from there, in residency, not only are podiatrists rotating through internal medicine, emergency medicine, anesthesiology, general surgery, vascular surgery, orthopedic surgery; but we also spend a great majority of our time doing foot and ankle surgery. And so, we are learning techniques. We are learning about different symptoms, seeing patients with these things and so there is just a lot more training within the scope of what we are practicing and that’s not to say that orthopedists don’t know a lot about the foot or ankle. I’m just saying podiatrists are well-trained nowadays with the residency programs that they have and everything to know and be able to treat and diagnose people with foot pain and ankle pain with today’s patient population.
Melanie: Thank you for that answer. It definitely clears up some of the confusion about your specialty. So, how do you diagnose what the issue is? If someone comes in and says I have trouble in the morning, I hobble around, my heels are burning or what do you do to diagnose a heel issue?
Dr. Aveytua: Well first thing is a history, getting the history from the patient. When they say when they come in you say oh describing pain first thing in the morning with that first step and then after walking around a while, it starts to feel a little better; that kind of clues us into maybe what might be happening with the patient. They also describe that as also last thing after they get up after periods of rest and are having pain again, but it goes away after walking for a while, then the kind of leads us more to think plantar fasciitis. And then there are other things as well that can either hone us in on what we think it may be or not and then a physical. So, the history and physical are really key in making the diagnosis for what may be going on with the patient and their heel pain. But just finding – like I said, the history and physical are really key in to getting that and just asking them has there been any change in their weight. Has there been a change in their job and those sorts of things whether it is one foot or both feet and then what kind of shoes they are wearing.
Melanie: Shoes are so important aren’t they and people don’t really realize when they are exercising and the stress that we put as I said in my intro doctor, about the stress that we put on our feet. Tell us when somebody does suffer from plantar fasciitis or heel spurs or any of these other issues we are talking about today; what do you recommend as far as shoes?
Dr. Aveytua: You know a good supportive sneaker goes a long way. Something that’s going to support the arch, because with plantar fasciitis in general, when you are taking that step, that plantar fascia is stretching out and so it’s tugging on your heel bone and so when someone says oh I have a heel spur, they may think the spur is what is causing the pain. When really the heel spur is not causing your pain. That just means you have really tight ligaments and plantar fascia on the bottom that has been tugging at your bone for so long that it has caused this spur to develop. But it’s that tugging of the plantar fascia with each step when you are barefoot that it is just causing that pain to develop. So, if you can kind of give your body a period of rest where you are wearing a good supportive shoe like a sneaker, just Basics or New Balance some sort of running shoe that’s got good supportive arch support; then that’s not going to have your arch stretch as much which will decrease some of your pain. There’s also some decent over-the-counter orthotics that can help or insoles. But really custom orthotics can help a lot of people relieve some of their pain as well.
Melanie: Well I mean so what is the intention of an orthotic. It provides support under the arch and then takes off some of that pressure on that heel?
Dr. Aveytua: Well it’s not only the arch support, but it’s keeping your foot in a proper position to where it’s not going to have as much pain whereas if your foot is rolling in or rolling out and that may lead to other parts of your feet not working properly. The arch or the orthotic is really just to kind of help support the heel and the arch in the proper position.
Melanie: Doctor what are some at home treatments, things that people can do at home to help if they suffer from plantar fasciitis?
Dr. Aveytua: Well some things that they can try at home before seeing is stretching, doing a wall stretch, just really stretching your calf. And it may seem counterintuitive, the bottom of my foot hurts, not the back, but you want to stretch out your calf because sometimes a really tight calf can cause that plantar fasciitis so, doing a wall stretch, holding it for ten seconds and I tell my patients, do that ten times a day. I don’t want you to do it for 100 seconds, right first thing in the morning. But I want ten seconds just ten times throughout the day, so you are constantly stretching it and kind of getting that going. Another thing you can try doing is taking a water bottle, putting it in the freezer and then letting it become ice and then at night, you are rolling your foot over that bottle, massaging that area. You can also try gold ball, put it in the freezer so it is ice. That may help and that might help feel good. Just getting some ice on it can do a lot for some of the inflammation. You could also try doing a towel or a belt and just sitting down, laying down with your knee extended and have that belt or that towel over the ball of your foot and just pulling it back to kind of stretch it out as well. But stretching is really key and even trying like if your medical history is okay and you have had anti-inflammatories before you could try either Tylenol, but more importantly I would like ibuprofen or Naprosyn, naproxen over-the-counter and just taking that for three or four days seeing if that can help reduce it.
Melanie: So, then people have heard about Achilles tendonitis as well. So, they hear about all of these issues doctor and it could be any one of them. So, tell us about Achilles tendonitis and what causes it. What’s the most common cause?
Dr. Aveytua: Achilles tendonitis is – so the Achilles is on the back of the heel. It can both a lot of people. Basically, it’s painful inflammation on the distal part, or I guess the part closest to the heel bone. It can be associated with an area where there is not a great blood supply, that’s called the Watershed area. Also, this sometimes can be associated with calcification at that level of the insertion, meaning there’s just not enough or it’s just kind of dried out over time, the tendon and that can just tug again, like the plantar fascia, tugging on the heel bone and if it’s tugging where it inserts, that’s actually called enthesopathy or enthesitis which can just be tugging on that heel bone. If it’s up above, you can have like micro tears of the tendon. That’s just due to repetitive trauma and so a lot of times with this, this incidence is young athletes or people that have had problems with their tendons in the past. They may not have torn it completely, but they have like a partial tear and those partial tears can add up and become painful for patients later on. Sometimes, the history that a patient may describe is a kind of slow onset, chronic heel pain with some swelling. Sometimes it can even be aggravated by shoes or it’s relieved when they are walking either barefoot in some cases or if they are wearing a heel, an elevated heel, which may seem kind of counterintuitive. How could someone feel better wearing a shoe with a heel or a high heel, but that might be if they have a tight Achilles or if they have had so much when you are wearing a heel, you are not putting as much tension on your Achilles.
Melanie: That’s so interesting. What a great explanation and when does heel pain or foot problems, when do you discuss the word surgery with patients? When does it come down to that?
Dr. Aveytua: For me personally, I like to go a little more conservative first before jumping into surgery depending on what it is. And I think, I don’t know if this is the general consensus across the board, but I would just encourage every patient to kind of assess the risks and benefits which I think most doctors would discuss risks and benefits of different treatment options for patients. For me, I want to see, I’d like an x-ray just to make sure there is no fracture, make sure there is no stress fracture or anything going on. And then doing a treatment such as an anti-inflammatory medication or even a low dose steroid for a few days to see if that can kind of get rid of some of the inflammation that is going on. Sometimes giving an injection, a steroid injection with local anesthetic, that will numb up the area right away and hopefully get rid of the inflammation and that may be all that a patient needs. But, in certain cases when they don’t get better with conservative treatment, medication, steroid injections or resting it, putting them maybe in like a CAM boot which is a controlled ankle motion boot, that’s what CAM stands for. That’s where they may benefit from having surgery to release the plantar fascia or in the case of Achilles tendonitis; if they are in that boot and they are resting and they are not getting better; they may have a partial tear which could benefit from doing surgery and so, for my approach, like I said, I like to try a little more conservative stuff first and that way I think the patient feels a little more comfortable. We have exhausted our conservative options and now we can move on to doing something that may be beneficial and beneficial for the patient in the long run as well.
Melanie: Dr. Aveytua, wrap it up for us with your best advice as a podiatrist of what you want people to know about keeping healthy feet and when you feel it’s important that they come to see you if they are suffering from some problems that really limit their daily activities.
Dr. Aveytua: So, I think if you are having feet pain and it’s been going on for even a couple of weeks I would say go see a doctor and just go see a podiatrist and find out what’s going on. It may be something simple or it may be more complex. There are different things that can cause heel pain. It’s not always going to be plantar fasciitis. It’s not always going to be Achilles tendonitis. There could be like I said, the nerve could be bothered and that could be a tarsal tunnel syndrome, or it could be something from not wearing proper shoes. And so, just coming to visit and seeing me or seeing a podiatrist in general, what it will do is we will really just kind of make sure we nip the problem in the bud sooner rather than waiting and trying this out for months and months. I have a friend that lives across the country and he’s been telling he has been having feet pain for over a year and he was telling me his history and how it’s been hurting him first thing in the morning and then. I knew what he had right away, but he didn’t, and he was just like oh it’s kind of been bothering me. So, if he had gone to see someone where he lives, after a month, he could have had this healed but I talked to him over the phone some things that he could do and then was able to help him and now he’s – and this was just over this past weekend – now he’s feeling a lot better and he’s back to his daily normal daily activities. But to have it carry on and drag out for so long can be a real hinderance and painful for people that may not be necessary.
Melanie: That’s great information doctor, thank you so much for joining us and sharing your expertise on heel pain. There are so many foot topics we could talk about. So, thank you so much for being with us. You’re listening to Memorial Health Radio with Memorial Health System. For more information please visit www.mhsystem.org, that’s www.mhsystem.org. This is Melanie Cole. Thanks so much for listening.
Do You Suffer From Undiagnosed Heel Pain?
Melanie Cole (Host): You know our feet can handle a lot of stress, but if you put too much of a load on them; it can, over time, cause damage. When heel pain begins to limit your daily activities, it might be time to see a podiatrist to assess your issue. My guest today is Dr. Ian Aveytua. He’s a podiatrist with Memorial Health System. Dr. Aveytua what are some of the most common causes of heel pain that you see every day?
Ian Aveytua, DPM (Guest): Some of the most common heel pain patients that come into our office usually have plantar fasciitis, probably number one. And then another one that’s pretty common that can be assessed is tarsal tunnel syndrome or nerve impingement and then even a bursitis that could be causing some pain for a lot of patients.
Melanie: Dr. Aveytua before we talk about diagnosis of some of these issues; please answer this common question that listeners might have. Why would they go see a podiatrist or why would they go see an orthopedic surgeon when they have foot problems? Please explain why what you do as a specialist in the feet is the reason to see a podiatrist.
Dr. Aveytua: Yeah, so both podiatrists and orthopedists do a lot of the same work. Orthopedists depending on what their specialty is will range, do special fellowship training or surgery for the whole body and sometimes they may do a lot of cases in the foot or ankle and sometimes they may not. They may just know the body in general. With podiatrists, the first two years of medical school or podiatry school are with a lot them are the same classes as medical school and then the last two years kind of start to focus in and hone in on the foot and ankle. And then from there, in residency, not only are podiatrists rotating through internal medicine, emergency medicine, anesthesiology, general surgery, vascular surgery, orthopedic surgery; but we also spend a great majority of our time doing foot and ankle surgery. And so, we are learning techniques. We are learning about different symptoms, seeing patients with these things and so there is just a lot more training within the scope of what we are practicing and that’s not to say that orthopedists don’t know a lot about the foot or ankle. I’m just saying podiatrists are well-trained nowadays with the residency programs that they have and everything to know and be able to treat and diagnose people with foot pain and ankle pain with today’s patient population.
Melanie: Thank you for that answer. It definitely clears up some of the confusion about your specialty. So, how do you diagnose what the issue is? If someone comes in and says I have trouble in the morning, I hobble around, my heels are burning or what do you do to diagnose a heel issue?
Dr. Aveytua: Well first thing is a history, getting the history from the patient. When they say when they come in you say oh describing pain first thing in the morning with that first step and then after walking around a while, it starts to feel a little better; that kind of clues us into maybe what might be happening with the patient. They also describe that as also last thing after they get up after periods of rest and are having pain again, but it goes away after walking for a while, then the kind of leads us more to think plantar fasciitis. And then there are other things as well that can either hone us in on what we think it may be or not and then a physical. So, the history and physical are really key in making the diagnosis for what may be going on with the patient and their heel pain. But just finding – like I said, the history and physical are really key in to getting that and just asking them has there been any change in their weight. Has there been a change in their job and those sorts of things whether it is one foot or both feet and then what kind of shoes they are wearing.
Melanie: Shoes are so important aren’t they and people don’t really realize when they are exercising and the stress that we put as I said in my intro doctor, about the stress that we put on our feet. Tell us when somebody does suffer from plantar fasciitis or heel spurs or any of these other issues we are talking about today; what do you recommend as far as shoes?
Dr. Aveytua: You know a good supportive sneaker goes a long way. Something that’s going to support the arch, because with plantar fasciitis in general, when you are taking that step, that plantar fascia is stretching out and so it’s tugging on your heel bone and so when someone says oh I have a heel spur, they may think the spur is what is causing the pain. When really the heel spur is not causing your pain. That just means you have really tight ligaments and plantar fascia on the bottom that has been tugging at your bone for so long that it has caused this spur to develop. But it’s that tugging of the plantar fascia with each step when you are barefoot that it is just causing that pain to develop. So, if you can kind of give your body a period of rest where you are wearing a good supportive shoe like a sneaker, just Basics or New Balance some sort of running shoe that’s got good supportive arch support; then that’s not going to have your arch stretch as much which will decrease some of your pain. There’s also some decent over-the-counter orthotics that can help or insoles. But really custom orthotics can help a lot of people relieve some of their pain as well.
Melanie: Well I mean so what is the intention of an orthotic. It provides support under the arch and then takes off some of that pressure on that heel?
Dr. Aveytua: Well it’s not only the arch support, but it’s keeping your foot in a proper position to where it’s not going to have as much pain whereas if your foot is rolling in or rolling out and that may lead to other parts of your feet not working properly. The arch or the orthotic is really just to kind of help support the heel and the arch in the proper position.
Melanie: Doctor what are some at home treatments, things that people can do at home to help if they suffer from plantar fasciitis?
Dr. Aveytua: Well some things that they can try at home before seeing is stretching, doing a wall stretch, just really stretching your calf. And it may seem counterintuitive, the bottom of my foot hurts, not the back, but you want to stretch out your calf because sometimes a really tight calf can cause that plantar fasciitis so, doing a wall stretch, holding it for ten seconds and I tell my patients, do that ten times a day. I don’t want you to do it for 100 seconds, right first thing in the morning. But I want ten seconds just ten times throughout the day, so you are constantly stretching it and kind of getting that going. Another thing you can try doing is taking a water bottle, putting it in the freezer and then letting it become ice and then at night, you are rolling your foot over that bottle, massaging that area. You can also try gold ball, put it in the freezer so it is ice. That may help and that might help feel good. Just getting some ice on it can do a lot for some of the inflammation. You could also try doing a towel or a belt and just sitting down, laying down with your knee extended and have that belt or that towel over the ball of your foot and just pulling it back to kind of stretch it out as well. But stretching is really key and even trying like if your medical history is okay and you have had anti-inflammatories before you could try either Tylenol, but more importantly I would like ibuprofen or Naprosyn, naproxen over-the-counter and just taking that for three or four days seeing if that can help reduce it.
Melanie: So, then people have heard about Achilles tendonitis as well. So, they hear about all of these issues doctor and it could be any one of them. So, tell us about Achilles tendonitis and what causes it. What’s the most common cause?
Dr. Aveytua: Achilles tendonitis is – so the Achilles is on the back of the heel. It can both a lot of people. Basically, it’s painful inflammation on the distal part, or I guess the part closest to the heel bone. It can be associated with an area where there is not a great blood supply, that’s called the Watershed area. Also, this sometimes can be associated with calcification at that level of the insertion, meaning there’s just not enough or it’s just kind of dried out over time, the tendon and that can just tug again, like the plantar fascia, tugging on the heel bone and if it’s tugging where it inserts, that’s actually called enthesopathy or enthesitis which can just be tugging on that heel bone. If it’s up above, you can have like micro tears of the tendon. That’s just due to repetitive trauma and so a lot of times with this, this incidence is young athletes or people that have had problems with their tendons in the past. They may not have torn it completely, but they have like a partial tear and those partial tears can add up and become painful for patients later on. Sometimes, the history that a patient may describe is a kind of slow onset, chronic heel pain with some swelling. Sometimes it can even be aggravated by shoes or it’s relieved when they are walking either barefoot in some cases or if they are wearing a heel, an elevated heel, which may seem kind of counterintuitive. How could someone feel better wearing a shoe with a heel or a high heel, but that might be if they have a tight Achilles or if they have had so much when you are wearing a heel, you are not putting as much tension on your Achilles.
Melanie: That’s so interesting. What a great explanation and when does heel pain or foot problems, when do you discuss the word surgery with patients? When does it come down to that?
Dr. Aveytua: For me personally, I like to go a little more conservative first before jumping into surgery depending on what it is. And I think, I don’t know if this is the general consensus across the board, but I would just encourage every patient to kind of assess the risks and benefits which I think most doctors would discuss risks and benefits of different treatment options for patients. For me, I want to see, I’d like an x-ray just to make sure there is no fracture, make sure there is no stress fracture or anything going on. And then doing a treatment such as an anti-inflammatory medication or even a low dose steroid for a few days to see if that can kind of get rid of some of the inflammation that is going on. Sometimes giving an injection, a steroid injection with local anesthetic, that will numb up the area right away and hopefully get rid of the inflammation and that may be all that a patient needs. But, in certain cases when they don’t get better with conservative treatment, medication, steroid injections or resting it, putting them maybe in like a CAM boot which is a controlled ankle motion boot, that’s what CAM stands for. That’s where they may benefit from having surgery to release the plantar fascia or in the case of Achilles tendonitis; if they are in that boot and they are resting and they are not getting better; they may have a partial tear which could benefit from doing surgery and so, for my approach, like I said, I like to try a little more conservative stuff first and that way I think the patient feels a little more comfortable. We have exhausted our conservative options and now we can move on to doing something that may be beneficial and beneficial for the patient in the long run as well.
Melanie: Dr. Aveytua, wrap it up for us with your best advice as a podiatrist of what you want people to know about keeping healthy feet and when you feel it’s important that they come to see you if they are suffering from some problems that really limit their daily activities.
Dr. Aveytua: So, I think if you are having feet pain and it’s been going on for even a couple of weeks I would say go see a doctor and just go see a podiatrist and find out what’s going on. It may be something simple or it may be more complex. There are different things that can cause heel pain. It’s not always going to be plantar fasciitis. It’s not always going to be Achilles tendonitis. There could be like I said, the nerve could be bothered and that could be a tarsal tunnel syndrome, or it could be something from not wearing proper shoes. And so, just coming to visit and seeing me or seeing a podiatrist in general, what it will do is we will really just kind of make sure we nip the problem in the bud sooner rather than waiting and trying this out for months and months. I have a friend that lives across the country and he’s been telling he has been having feet pain for over a year and he was telling me his history and how it’s been hurting him first thing in the morning and then. I knew what he had right away, but he didn’t, and he was just like oh it’s kind of been bothering me. So, if he had gone to see someone where he lives, after a month, he could have had this healed but I talked to him over the phone some things that he could do and then was able to help him and now he’s – and this was just over this past weekend – now he’s feeling a lot better and he’s back to his daily normal daily activities. But to have it carry on and drag out for so long can be a real hinderance and painful for people that may not be necessary.
Melanie: That’s great information doctor, thank you so much for joining us and sharing your expertise on heel pain. There are so many foot topics we could talk about. So, thank you so much for being with us. You’re listening to Memorial Health Radio with Memorial Health System. For more information please visit www.mhsystem.org, that’s www.mhsystem.org. This is Melanie Cole. Thanks so much for listening.