Heel pain is a term that we give to a number of conditions that can cause pain surrounding the heel bone.
Every step you take is endured by your muscles, tendons, ligaments and bones. When everything is working in synergy we can function without pain and tolerate large stresses placed upon our feet. Not every foot is perfect but when we get pain, it is our first warning sign that something needs to be corrected or changed.
The first step towards managing heel pain is getting a clear diagnosis. There are many different structures in the foot that can cause heel pain and there are many different reasons why those structures might be irritated.
This is the reason why we use the combined knowledge of a physio specializing in strength and stability of the lower limb, as well as a podiatrist specializing in foot structure and mechanics.
Listed here are some of the differential causes of heel pain:
Plantar Fasciitis is common the general population, causing up to 15% of foot problems. It is most typical in the ages above 40 years. Plantar fasciitis can be felt as moderate to severe pain along the bottom of the foot and under the heel. It is often noticed more so after getting out of bed in the morning or when getting up after a prolonged period of rest. The pain is usually come on gradually and can last for years.
More on Plantar fasciitis –
The term fasciitis literally means inflammation of the fascia, but most cases are more of a degenerative change rather than inflammatory. A new term being used to accurately describe the condition is plantar fasciosis. We often see that the plantar fascia can become thickened on ultrasound and in most cases the pain is on the bottom of the heel at the junction of the plantar fascia and the heel bone, known as the calcaneus. Sometimes there can be a complete rupture or tear to the plantar fascia.
Plantar fascia function –
The plantar fascia is a strong ligament that runs the length of your foot from the heel bone to the toes. Although it is strong, it is not very elastic, so repeated movements, such as running, can overstretch it and partially tear or pull it away from the heel bone. The plantar fascia can also overstretch or tear at the arch.
In normal functioning of the heel, the plantar fascia acts as a shock absorber and support mechanism for the arch of the foot. During gait, or movement, the plantar fascia acts like a spring which winds and unwinds to conserve energy and provide propulsion. This is called the “windlass” mechanism. Tension increases while the foot is on the ground to store the energy and is then released during toe-off to help with acceleration.
Part of the protocol for treating this injury involves “unloading” this fascia with certain taping methods whilst also supporting it with correct footwear/inserts. Strengthening exercises for the foot muscles is very important to ensure the natural stability of the fascia is regained.
X-ray evidence suggests that approx 10% of the population have heels spurs but do not have associated pain. In some people the spur can be a complication for treatment the plantar fasciitis. The spur often grows towards the fascia from the heel bone as a result of chronic tensile forces where the fascia inserts onto the bone.
A note on heel spurs –
A heel spur doesn’t necessarily CAUSE pain. The spur does not have to be removed to resolve the heel pain and can remain on the bone without a problem. This is important because it creates a shift in a patient’s mindset to that of being able to address the problem.
Sever’s Disease (calcaneal apophysitis)
This problem is an inflammation of the growth plate in the heel of the younger population. It is most common between 5 and 12 years of age, particularly in those that are active. Both heels are affected in over half of the people that have this injury.
This condition is often felt as tenderness at the insertion of the Achilles tendon onto the back of the heel. There may not be signs of swelling but these is usually an increase of pain after activity, such as running. Generally, the heel pain will settle with rest, but will return with an increase in activity.
Haglund’s deformity (heel bump)
Haglund’s deformity can occur in one or both feet. The signs and symptoms include a noticeable bump on the back of heel, pain in the area where the Achilles tendon attaches to the heel, swelling in the back of the heel and redness near the inflamed tissue.47
Patients present with swelling and tenderness around the Achilles tendon. In most cases, the tender region is well localized, and the patient holds the foot plantar flexed to relieve the discomfort. Passive dorsiflexion will aggravate the pain.34 Morning stiffness is common, but typically pain is increased with activity and relieved by rest.48
A trapped nerve can cause pain, numbness or tingling sensation almost at any place at the back, inside or bottom of the heel. Sometimes there are other symptoms such as swelling or discoloration if the trapped nerve was caused by a sprain, fracture or other injury.16
Bursitis involving the affected heel causes pain in the middle of the undersurface of the heel that often worsens with prolonged standing and pain at the back of the heel that worsens if the patient bends his or her foot up or down.16
Heel Pad Contusion
Also known as a bruised heel, is where there is an acute or chronic force is placed on the heel bone causing injury to the heel fat pad and sometimes the bone, if severe enough.
Calcaneal Stress Fracture
This is linked to repetitive stress on the actual heel bone, strenuous exercise, sports, or heavy manual work. Runners are particularly prone to stress fracture in the metatarsal bones of the foot. It can also be caused by osteoporosis.
Tarsal Tunnel Syndrome
A large nerve in the back of the foot becomes pinched or entrapped (compressed). This is a type of compression neuropathy that can occur either in the ankle or foot, and can create pain, pins and needles, and swelling in the foot. Usually this problem occurs due to poor foot biomechanics.