Q I am a 70-year-old man. I have had pain in my heel for five years.

It started with my left heel. The pain subsided after I used ready-made insoles. But, a year ago, I felt pain in my right heel.

I have tried various ready-made insoles. I use slippers with thicker heels and higher arches. But the pain is still there.

I recently bought a pair of made-to-order insoles. I was told I have an arch problem on my right foot and I am flat-footed on the left.

I don't feel the pain in the arch but there is pain in my heel cup.

I have tried to stand on my toes for one minute daily and swim once a week. Unfortunately, the pain continues to come and go.

I weigh about 75kg and, based on my BMI, I should reduce my weight to 67.8 to 71.6kg. What can I do?

A Heel pain can affect everyone. There are many possible causes, such as stress fracture of the heel bone, bursitis and connective tissue injury.

Treatment options differ, depending on the cause.

You have described taking positive steps towards treating the condition.

However, it is unclear if the advice was given by a trained healthcare professional. It is possible that you might have performed the steps inaccurately. This could be the reason the pain is still there.

If you have not sought profes- sional help, we suggest that you see a general practitioner (GP) to assess your condition more accurately. The GP will refer you to a specialist, if necessary.

Specialists like orthopaedic surgeons will usually ask for an X-ray of the foot to check for the presence of bony spurs (bony growths) around the heel bone.

The severity of conditions such as plantar fasciitis and Achilles tendon degeneration can be assessed from the size and location of bony spurs in the heel bone.

The condition that you have could be plantar fasciitis, which affects many people.

This is caused by the degeneration and inflammation of the thick band of tissue (ligament) that runs along the sole of your foot.

Painkillers may be prescribed and you may be advised to lose some weight to help reduce the stress on your feet.

You may be referred to the podiatrist for non-invasive treatment to ease the pain.

The podiatrist will do a thorough foot assessment, teach you proper stretching exercises, provide pre- fabricated or custom-made insoles, give advice on appropriate footwear as well as help you modify your lifestyle and activities that might aggravate the pain.

Alternative treatments, such as therapeutic ultrasound or shockwave therapy, can be considered if the first-line treatment is insufficient.

The rationale of wearing insoles is to support the painful foot and reduce excessive pulling of the connective tissue that is linked to the heel bone. However, merely fitting the patient with a pair of insoles will not suffice as it is only a small part of a comprehensive heel-pain treatment plan.

If the patient does not respond well to conservative management methods and the pain persists, the orthopaedic surgeon will offer a platelet-rich plasma (PRP) injection - which is drawn from the patient's blood - into the area where there is maximum pain.

This allows the degenerated plantar fascia to gradually recover by regenerating new tissue, which results in permanent pain relief.

This procedure carries minimum risk and is better than using steroid injections to relieve the pain. The latter can result in a weakened plantar fascia ligament, which could then rupture.

Many patients have benefited from this procedure and are relieved of their pain after three to four weeks.

Surgery will be offered as the last resort to "release" the plantar fascia. This involves key-hole surgery to cut the tight bands of the fascia.

Dr Chee Yu Han

Consultant, division of foot & ankle surgery, department of orthopaedic surgery, National University Hospital

Mr Supapong Supantamart

Podiatrist, NUH Rehabilitation Centre

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