Heel pain can become a chronic disabling problem if not accurately diagnosed at an early stage and the appropriate treatment implemented. It is usually a multifactorial complaint where the pain is a symptom in combination with others, not a stand alone condition.
Heel pain is common and will invariably be due to a combination of factors. Various conditions affecting the heel area include: Heel Spurs, Plantar Fasciitis, Calcaneal Apophysitis (Sever’s Disease), Achilles Tendonitis, Myofascial Trigger Point pain, Sciatica, Tarsal Tunnel Syndrome, Entrapment of the Lateral Plantar Nerve, Rupture of the Plantar Fascia, Fracture and Soft Tissue Trauma.
Plantar fasciitis and heel spurs are often blamed for most heel pain. In our experience, true plantar fasciitis is only relevant to a small percentage of cases and most heel spurs exist with no symptoms for many years and may or may not be implicated in the actual pain.
Aggravating Factors for Heel Pain
- Overtraining or training without adequate preparation, warm up and stretching
- Constant, prolonged contact with hard and uneven surfaces
- Structural/biomechanical abnormalities placing joints and soft tissue under stress
- Inappropriate footwear
- Work environment
Causes of Heel Pain
All causes of heel pain should be considered before a treatment regimen is undertaken.
Heel Spurs – These are small boney spurs that often develop on the bottom or back of the heel bone (calcaneus). The evidence suggests that there is no correlation between pain and the presence of absence of boney spurs. They generally do not cause any problems in themselves. Instead, the pain really arises from inflammation and swelling of the plantar fascia and other soft tissue structures attached to it.
Plantar Fasciitis – The most commonly diagnosed (rightly or wrongly) cause of heel pain. It is due to a biomechanical imbalance leading to strain of the long ligament that attaches the base of the heel bone to the ball of the foot and lies superficially to the layers of muscle in the arch of the foot. The most common symptom reported is pain on getting out of bed in the morning, or after sitting for a period of time. Orthotic devices are the mainstay of ongoing conservative treatment for patients with plantar fasciitis as very often an overpronated foot is associated with this pain and controlling the excessive flattening and lengthening of the arch on weightbearing relieves the tension and pain.
Trigger Points – The finding of trigger points in relation to heel pain is paramount. Trigger point release can give relief from pain very quickly, even in longstanding cases of chronic and disabling heel pain. Heel pain can also be referred from trigger points in the calf muscles and foot muscles. Trigger points are tight, contracted spots in muscles that can refer pain, tingling, heat or numbness to distant areas. The soleus, gastrocnemius (calf muscles) and the quadratus planta muscle (sole of foot) are often implicated in heel pain. This referred pain is felt in exactly the same place as “plantar fasciitis” and there is some speculation that this cause is actually more common than inflammation of the plantar fascia itself. Pain can also be referred from nerves in the lower back to the heel.
Stress Fractures – Stress fractures more commonly occur in those who are very active e.g. athletes, or those with weaker bones as found in people with osteoporosis. The symptoms are much the same as those of plantar fasciitis and often occur after a sudden increase in physical activity. Plaster casts may be required if the fracture does not resolve.
Bursitis – Pain at the back of the heel where the Achilles Tendon attaches to the bone may be due to bursitis. This sac of fluid protects the tendon from a prominent edge on the heel bone as it pulls the heel upwards and can become inflamed if there is too much friction or if the boney prominence is marked. Shoes with a curved heel counter may irritate the bursa forcing the Achilles tendon into closer contact with the heel bone. Signs of bursitis include swelling, redness, acute tenderness and pain on moving the ankle. Treatment will include rest, anti-inflammatories, trigger point therapy, footwear modification, and orthotics if necessary.
Sciatica – Heel pain can occur secondarily to sciatica as a result of pressure on the L5-S1 nerve root. This nerve provides innervation to the back of the thigh, and the gluteal, anterior, posterior and lateral leg muscles, as well as sensation to the heel. Muscle weakness in any of these areas as well as sharp pain running down the leg towards the heel may be felt. Treatment will include an investigation of back problems, gait issues, and a check for leg length imbalance.
Bruising – A ‘stone’ bruise can sometimes be responsible for heel pain. It is simply a bruise of the fibrofatty pad protecting the heel bone or a bruise of the calcaneus itself and is usually related to trauma or footwear problems.
Heel Pain in Children – In order for a childs skeleton to grow to their mature size each bone has one or more cartilaginous growth plates so that new bone can be laid down over the years to increase the size or length of that bone. These growth plates are found at the ends of the bones and are visible on an X-ray as relatively dark lines through the whiter bone.
The most common cause of heel pain in children aged between 9 and 13 is inflammation of the heels growth plate called Sever’s Disease or “calcaneal apophysitis”. The pain is felt at the back and sides of the heel bone especially when squeezed laterally and is much worse with running activities, walking up stairs or inclines, and squatting positions. Because of the tendency for more physical activity in this age group, Sever’s affects boys more frequently than girls. Heavier children and those who are extremely active are more often affected.
The calf muscles combine to form the Achilles tendon which attaches to the back of the heel bone. It is the thickest and strongest tendon in the human body for a very good reason – it must be able to lift and propel the entire body single handedly against gravity by raising the back of the foot off the ground and producing enough force to cause us to move forward. Therefore there is a huge amount of force being applied to the heel bone where the tendon attaches at every single step or movement. However in children, there is only a small sliver of bone that the tendon actually connects with and this sliver is separated from the rest of the heel bone by the growth plate so injury to the growing bone is quite easy. In severe cases, the child will limp as they walk or ‘toe walk’ to take pressure off the backs of their heels.
A pronated (rolled in) foot is more prone to Sever’s as are children with tight calf muscles. Children in this age group are usually growing rapidly and are particularly active so their muscle length is often relatively short compared with their bone growth. Tight muscles apply a lot more tension over a longer time at their attachment to bone and these children must incorporate a consistent and effective stretching programme into their treatment regime.
Treatment for Sever’s is theoretically simple, but difficult in a practical sense!! Since it affects children almost exclusively that are fit, active and competitive, reducing or even halting their sporting endeavours sometimes proves impossible and compromises must be made.
Treatment for Sever’s Disease:
- Cut back or stop sporting activities
- Cushioned heel lifts to reduce the pull of the Achilles tendon and provide some shock absorption
- Stretching – only after inflammation has subsided enough not to cause pain
- Icing after activity for 20 mins, repeated 2-3 times
- Anti-inflammatories if necessary
- Orthotics will be prescribed if a biomechanical imbalance is identified as a causative factor. This may also reduce the probability of a recurrence.
- Avoid going barefoot
- Strapping or tape may be helpful during activity to limit movement
- Cast immobilization may be required in severe cases
Rupture of Plantar Fascia – An uncommon source of heel pain – it usually presents as sever and sudden pain in the medial arch area following some sort of trauma. An MRI is useful to give a definitive diagnosis. Some patients have been misdiagnosed and treated unsuccessfully for several months with steroid injections for presumed plantar fasciitis. Immobilisation and anti-inflammatory treatment will generally be required.
Entrapment of the Lateral Plantar Nerve – This condition presents as a burning sensation on the bottom of the heel that is worsened by daily activities and may even persist during rest periods. It involves entrapment of the lateral plantar nerve resulting in plantar medial heel pain. The heel may be painful and/or tingling to touch. The same treatment options used for plantar fasciitis are effective in treating this complaint.
Tarsal tunnel Syndrome – Tarsal Tunnel Syndrome is caused by compression of the posterior tibial nerve on the inside of the ankle. Inflammation or enlargement of the nerve in this area is responsible for the entrapment. Nerve compression often causes heel pain with a tingling sensation underneath and on the inside of the heel that tends to worsen with weightbearing and walking. It is usually relieved by rest, elevation, or by rubbing the area. Actually pinpointing an area of specific pain can prove difficult. Nerve conduction tests may be useful for diagnosis.
Conditions that may cause compression of the posterior tibial nerve include a soft tissue mass, bone callous around the medial malleolus from previous fracture, inflammation of one of the tendons running through the tarsal canal and excessive foot pronation that increases tension on the posterior tendon and corresponding nerve.
Treatment will involve the reduction of pronation forces, rest, anti-inflammatories, and possible surgery to decompress the nerve.
A number of systemic autoimmune disease processes can occasionally cause heel pain e.g. rheumatoid arthritis, ankylosing spondylitis, gout, psoriatic arthritis, Reiter’s syndrome, Behcet’s syndrome, and systemic lupus erythematosis. These possibilities should be considered when discussing your symptoms with your doctor or podiatrist.
Podiatric Investigation of Heel Pain:
The differential diagnosis of heel pain is based mainly on the medical history and clinical presentation. Further tools of investigation will include:
- Gait and postural assessment, biomechanical evaluation
- Trigger point assessment
- Footwear assessment
- Range of motion studies
- Discussion of work and leisure activities
- Changes in activity and or footwear that may have placed extra strain on the foot
- Ultrasound of plantar ligaments of the foot
- X-ray for fracture or spur if necessary
Conservative treatment of heel pain should involve control of the inflammation and correction of the biomechanical factors that have produced the situation. Patient education is needed so that they can understand and actively participate in the recovery process. Patients need to understand the specific causes of their heel pain so that recurrence can be avoided. Treatment will involve some home therapies including stretches, massage, footwear changes and perhaps some modification to activity levels as well as clinical measures to speed up healing, pain relief, and return to normal function.
Applications utilized for the treatment of heel pain include:
- Trigger Point therapy
- Orthotic therapy
- Heel cushions
- Cortisone injection (risks involved and only to be used in extreme cases)
- RICE (rest, ice, compression, elevation)
See Stretching exercises for Treatment and Prevention