Heel pain is a common foot problem that affects people of all ages and genders. When a person with this condition tries to use the affected heel, it usually causes excruciating pain.
As a result of avoiding placing weight on the affected heel, some people may limp or develop an abnormal walking style.
People with heel pain often describe the pain as worse when they get up in the morning or after they’ve been sitting for long periods. After a few minutes of walking the pain decreases, because walking stretches the fascia. For some people, the pain subsides but returns after (American College of Foot and Ankle Surgeons, 2004)
To be able to effectively treat heel pain, you need to know the root cause. The longer you have heel pain, the more time it will take for it to heal.
The most common causes of heel pain are pain that occurs on the bottom of the heel (plantar fasciitis) and pain that occurs at the back of the heel (Achilles tendinitis).Heel pain is usually mild at first but it can become severe with time.
While mechanical factors are the most common causes, other causes include;
The most common causes for pain on the bottom of the heel are biomechanical abnormalities that lead to pathologic stress of the plantar soft tissues (1-7, pg 329 ACFAS).
Plantar fasciitis, heel spurs, and tarsal tunnel syndrome are some of the causes of pain on the bottom of the heel (Dr. Nicole G. Freels, FACFAOM, 2011.)
According to Podiatry Today, Plantar fasciopathy affects about 10% of the people in America and 1 to 2 million people in America every year.
A consensus is that the majority of patients with heel pain have changes of the plantar fascia.
Those who suffer from chronic pain have more damage. Heel thickening, swelling, and calcification are examples of changes.
Because there are fewer cells and less blood flow to this area of the foot, chronic changes can make healing difficult.
It could be nerve entrapment or a type of tissue that is not healing. New technologies are being tested to see if they can pinpoint the source of the problem.
A heel spur is a calcium deposit causing a bony protrusion on the bottom of the heel bone. (Rick Ansorge, WebMD, 2020, August 28)
Plantar fasciitis is where the thick band of tissue that connects the heel bone(calcaneum) with the rest of the foot (the plantar fascia) becomes damaged and thickened.
Heel spurs are not painful but they can cause heel pain when the plantar fascia is inflamed.
People usually experience pain when they first stand up in the morning or get up after sitting for a long time. When people first begin to walk, they often feel pain in their heels.
The pain may subside after a few minutes, but it will return if people stand for extended periods. The person’s weight can play a role in this.
Other factors, such as tight Achilles tendons and ill-fitting shoes, can worsen the situation.
Questions about pain are important.
A doctor will check the foot and ask about the pain, the amount of walking and standing the patient does, the type of footwear they use, and their medical history.
The doctor will also check for abnormalities in the movement of the joints.
Other physical exams may include
These may be enough to determine a diagnosis, although blood tests or imaging scans may be required in some severe cases.
Initial treatment options focus on relieving pressure on the plantar fascia’s insertion at the calcaneus.
these options include patient-guided stretching exercises of the calf muscles which include;
Other therapies focus on
Usually, there’s an improvement within 6 weeks of initial treatment and the continuation of the therapy session usually heals the pain However, if there’s little or no improvement, the patient should be referred to a podiatrist or foot specialist.
The second phase of treatment includes the continuation of initial treatment plus additional therapy.
It will take about 2- 3 months for 85-90% of patients to respond to treatment in this second phase (26-30), pg 330 ACFAS).
For those who show improvement both in phase 1 and phase 2 therapy should continue the treatment until they are treated.
If no improvement, other systemic diseases should be considered (31-37, pg 330 ACFAS).
During the third phase of treatment, cast immobilization should be added if not already done.
Other treatment options include surgical plantar fasciotomy. Plantar fasciotomy is a surgical procedure that separates your fascia from your heel bone to reduce strain.
Note that in the majority of cases, removal of the plantar heel spur does not treat plantar heel pain (48, 59-61) page 330 ACFAS).
Long-term biomechanical control of excessive pronation through orthotics is important to permanently treat the condition.
There are several fluid-filled sacs behind the heel bone that act as a cushion and a lubricant between muscles and tendons sliding over bone.
They are known as bursa. Repetitive or overuse of the ankle can cause the bursa to become inflamed or irritated leading to heel bursitis.
Symptoms include heel pain, when walking, running, or jumping, or when the area is touched.
The skin around the back of the heel may be red and warm to the touch, and standing on tiptoe may aggravate the pain.
It is most common in people who are just beginning an aggressive exercise routine.
Causes for heel bursitis include:
Treatment measures can include cortisone injections directly into the inflamed bursa, heel padding, orthotics, physical therapy with deep friction massage to break up the bursa, ultrasound +/- phonophoresis with the addition of steroids.
Bruising from rubbing irritation of the capillaries of the heel against the heel counter. This is most commonly seen in runners. Treatment best consists of protective padding and/or injection of the inflamed bursa with cortisone. The asymptomatic bursa can also be removed surgically.
As we mature the fatty tissue layer underneath our heels becomes thinner with less shock absorption for the heel which can lead to pain.
Cushioned insoles, orthotics with accommodation can be helpful
The most common causes of posterior heel pain or pain on the back of the heel are;
The Achilles tendon is the largest tendon (a band of tissue that connects muscle to bone) in the human body and is very strong (Dr. Nicole G. Freels, FACFAOM. (2011))
X-ray scans show spurring or erosions in the tendon. An MRI is the best way to find out the changes inside the tendon.
This condition is common with soccer players or after someone accidentally steps into a hole. The abrupt movement causes partial tears within the tendon which gradually fills with new bone formation.
Initial treatment is aimed at reducing pressure to the area such as heel lifts–for short term treatment–
Other treatment options include;
Local corticosteroid injections are not recommended as they can weaken the tendon and cause rupture. In difficult cases, surgery may be required.
Heel bumps OR Haglund’s Deformity are a bone enlargement on the back of the heel bone. These usually happen to athletes when their shoes rub up against their heels, and they can be made worse by the height or stitches of a shoe’s heel counter.
As a result, the heel suffers from painful bumps or bumps, making exercise extremely difficult.
It is more common in women between the ages of 20-30 (66-69) pg 334( ACFAS). Symptoms include acute pain and inflammation aggravated by shoe gear.
Initial treatment includes open-backed shoes, NSAID therapy, injections aimed at eliminating pressure and inflammation in the symptomatic area. Adjunctive physical therapy can be helpful.
If symptoms do not improve surgery may be required.
Preventing heel pain entails reducing stress on that area of the body.