Keene Office
61 Summer Street
Keene, NH 03431
Phone: 603-352-2944
Fax: 603-355-2273

Monadnock Community Hospital
Medical Arts Building
Suite 107
452 Old Street Road
Peterborough, NH 03458
Phone: 603-924-7100


There are many painful problems of the foot or ankle that people live with on a day-to-day basis. Many are not aware of easily provided medical solutions which are covered under their health insurance policies - problems such as heel pain. This person wakes up in the morning, steps down, and all of a sudden there is an aggravating aching pain in the heel of their foot. Usually, after limping around for a while, the intensity of their discomfort seems to decrease, becoming more tolerable, yet some degree of pain remains. The day progresses and soon lunch arrives. They sit down, eat their lunch, taking up the usual half hour to hour break, get up to begin the afternoon shift and, ouch! There it is again, that same intense aggravating pain they woke up with.

This is a very common scenario. Many people refer to this as a heel spur, although more accurately referred to as plantar fasciitis. On the bottom of the foot is a tendon like band of soft tissue called the plantar fascia. This attaches to a very localized spot at the heel bone. It fans out and inserts throughout the ball of the foot. The plantar fascia is only so long and can stretch so far and when it pulls at the heel inflammation and pain results. This problem is more commonly seen in people with flat feet or extremely high arches.

When the foot steps down it generally flattens out from the weight of the body. When this occurs excessively the plantar fascia stretches more than it can tolerate. The average person takes 10,000 steps a day. As the attachment to the heel bone is repeatedly stretched past its comfortable length, a pain cycle begins. Fibers are torn, the bone becomes irritated and inflammation sets in. In time, eventually spurs result. When your feet are at rest, such as when sleeping or a lunch break, the plantar fascia contracts and tightens up. The actual length decreases so that when you suddenly get up and step down the pulling at the heel bone is much greater and the pain more severe. Eventually this stretches and relaxes and the pain decreases but never seems to totally go away. The actual pain comes from the chronic inflammation of the fascia at the attachment to the heel and not the spurs, so you can have heel spur pain without actually having spurs.

Most people don't realize that plantar fasciitis can easily be treated. Conservative treatment focuses on mechanically resting the fascia and stopping the cyclic tearing and pulling of fibers. This is combined with the prescription of oral anti-inflammatory medication. The main goal is to support the arch so as to control flattening of the feet and quiet down the inflammation associated with it. Strapping and padding of the sole of the foot is a most effective way to support the fascia. This is easily done at the podiatrist's office. Should this be successful, the prescription of custom orthotics can help to permanently support the natural arch, thus prevent recurrence of heel pain. These devices are specific to each individual foot type.

Often, if heel pain has gone on untreated for many months, simple mechanical support and oral medications become ineffective. At this stage the podiatrist may require an injection of cortisone into the inflamed fascia. Cortisone serves as a potent anti-inflammatory medication working locally at the spot at which it is injected. More often than not one injection, combined with strapping and padding, can cure the symptoms completely. If not, a series of three injections usually solves the problem combined with biomechanical control.

When conservative treatment has failed, technology offers hope. Extracorporeal Shockwave Therapy (ESWT) is a non invasive treatment where repetitive shockwaves are used to interrupt the chronic inflammatory process and create an acute injury response which stimulates a process called neovascularization. With proper post-treatment care many can avoid the inevitable surgery.

In very rare circumstances some heel pain fails to respond to conservative treatment. These cases go on to surgical intervention. Traditionally this involved the surgical release of the plantar fascia from its attachment to the heel bone with or without the removal of the existing heel spur. This is performed through a conventional incision and required 3 - 4 weeks of convalescence. If surgery does become the answer, there now exist endoscopic surgical techniques in which heel spur surgery is performed through very tiny incisions with the use of a small camera lens and a television monitor. These people can be walking again without pain within 3 - 7 days. However, conventional surgery continues to be the most effective non conservative approach.

Not everybody responds to treatment in the same way, and each person is treated according to their own individual needs and complaints. So, if you find you're limping out of bed in the mornings and your heels ache throughout the course of the day, now you know. Help is just around the corner. Go get it.

Jonathan Pattavina DPM of the
Advanced Foot and Ankle Specialists
practices in Keene and Peterborough, NH.



ESWT - Extracorporeal Shockwave Therapy

Shockwave therapy is best known for its use in the treatment of kidney stones, referred to as ESWT or lithotripsy. Research has shown that shockwave therapy applied appropriately is beneficial for the treatment of several orthopedic and podiatric conditions. The FDA has granted clearance of ESWT for use in the United States. The treatment is non-invasive and performed on an outpatient basis, which means that it does not require surgery or a hospital stay. Patients may leave the treatment center shortly after the treatment is complete.

How Do Shockwaves Work?

Shockwave therapy works by triggering "messengers" that activate the body's own repair mechanisms to increase blood flow, change cell permeability and enhance healing. Also, shockwaves over stimulate the nerves, blocking the transmission of pain, which leads to a reduction in sensitivity.

  • Proven pain reduction after other conservative therapies, such as anti-inflammatory drugs, injections and physical therapy, have failed.
  • ESWT may eliminate the need for surgery and the associated risks and costs.
  • Short recuperation time allows for return to normal daily activities with improved quality of life.


What To Expect The Day Of Treatment.

Your physician will inject a numbing medication prior to your treatment, or anesthesia may be scheduled. During the treatment, the shockwave therapy head is placed in contact with the afflicted area. A gel is used to ensure that the therapeutic shockwaves are properly transmitted to the location of the pain. Your physician targets the therapeutic shockwave guided by ultrasound to achieve optimal results. The entire treatment process takes between 30 to 45 minutes.

After the treatment, you will be released and may be driven home by your designated driver. After a short period of resting and adhering to your physician's directions, you may return to your normal activities. Your physician will explain to you what to expect after your treatment. You will be scheduled for a follow-up evaluation with your physician.

On October 12, 2000, the FDA granted clearance of ESWT for the treatment of plantar fasciitis (chronic heel pain syndrome) and in July, 2002 granted clearance for Lateral Epicondylitis. Additional treatment indications are currently being researched worldwide.

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