What is Heel Pain?
Heel pain is the most common complaint that presents itself in podiatry clinics.
Basically anything that hurts in your heel is considered as heel pain.
The two most common places or heel pain are directly underneath the heel (plantar heel pain) and at the back of the heel (posterior heel pain).
The most common cause of plantar heel pain is plantar fasciitis and the most common cause of posterior heel pain is Achilles tendinopathy.
That is not to say that they will always be the cause, there are approximately 20 other lesser common conditions which could be the reason that you have heel pain.
That is why it is so important that your pain is assessed by a podiatrist so that you can get a quick diagnosis, and a treatment plan to get you back to your active best.
What I Will Cover in This Article:
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You want to exercise but...
It’s not only the pain that gets you down, it’s the fact that it’s preventing you from doing any exercise at all, meaning that you won’t get to the gym or go for a walk.
Some of us have been told by our doctors to lose weight for the good of our health, but we’re stuck in a vicious cycle of knowing we need the exercise, but not wanting to be in that much pain.
We Want to get You Moving
As podiatrists at Dynamic Podiatry, we see our key role as helping you to get back to the activities you enjoy, pain free.
We want you to get the absolute best out of yourself and your life.
To be that active person that you used to be, no matter what number is on your birth certificate.
In this article, I’m going to break down the causes of heel pain, what you can do to avoid it, and what you can do once it strikes.
Being proactive is the most effective way to stay healthy and disease free.
The Most Common Causes of Heel Pain
1. Plantar Fasciitis
Plantar fasciitis is the most commonly known and diagnosed of the heel pain conditions.
But it also tends to be over-diagnosed when other conditions are actually the culprit.
That is why it is important to be assessed by a practitioner with a lot of experience in dealing with biomechanics and painful lower limb conditions.
Plantar fasciitis is characterised by a very painful heel on the bottom surface upon rising in the morning.
Those first steps can be excruciating but will often ease off a little after walking around for a while.
As the condition progresses the patient may start to feel the pain towards the end of the day as well.
Especially if they sit down for a while after spending a day on their feet, and then stand back up, that killer pain hits back!
In the more chronic version of plantar fasciitis the pain is there whenever weight bearing with no respite throughout the day at all, until you finally sit down at the end of the day.
In some cases people will get a throbbing pain in the are even when in bed at night.
What is Plantar Fasciitis?
Plantar Fasciitis is damage to the strong band of tissue (the plantar fascia) that runs along the bottom of your foot from the heel to the toes.
Excessive forces or degrading of the tissue can cause micro-tears in the fascia.
If there are enough micro tears in one area a larger tear may form which will cause more severe dysfunction and take longer to heal.
This mostly occurs at the heel end of the plantar fascia
The earlier that you get diagnosed and treated for plantar fasciitis, the better your chance of getting timely relief of your symptoms.
The longer the condition is there, the more entrenched is the inflammation and the more changes occur to the surrounding tissues.
What Causes Plantar Fasciitis?
Although there are many causes of plantar fasciitis, they all have a similar result.
All of the causes listed below place increased tension (pulling force) on the plantar fascia, particularly at the part near the heel bone.
It is important to find out exactly what is leading to plantar fasciitis so that we can change that force and place it more evenly across the rest of the foot.
This is often achieved with a combination of improved footwear, custom insoles for your shoes, and exercises to stretch some muscles and strengthen others to restore balance to your lower limb.
Below are some of the many causes of plantar fasciitis:
- Pes planus (flat) or very pronated feet.
- Pes Cavus (high arched) or supinated feet.
- Being overweight
- Asymmetry due to a longer leg on one side or a tilt in the pelvis or a scoliosis.
- Age related changes to connective tissue.
- Activity related – performing very demanding activities such as running up and down hills when you are not well conditioned.
- Running on hard surfaces or uneven surfaces.
- Injury to another part of the body which causes compensation.
- Poor footwear – ballet flats, shoes that are too hard or too soft.
- One off injury – falling off a step or jumping down from something can cause tears.
Assessment of Plantar Fasciitis:
In order to find out the best treatment in your case the following diagnostic process should be followed:
- take a detailed history of the pain
- palpate gently to find which pieces of anatomy are painful.
- check the range of motion in your joints and the strength of your foot and leg muscles.
- perform a detailed stance and gait assessment (at Dynamic Podiatry we are lucky enough to have a high-tech plantar pressure which is integrated with a high speed camera. This gives us rare insight into exactly what is happening under the feet throughout each phase of gait.
Treatment For Plantar Fasciitis:
Once you have a diagnosis, treatment can be many different things and will depend on the causes of your condition but may include:
- Taping or strapping of the injured foot – often a taping technique called Low Dye Taping is employed to limit the amount of tension in the plantar fascia when weight bearing. Click here to see a video demonstration of Low Dye taping
- Custom of semi-custom foot orthotics (Click here to find out more about foot orthotics).
- Assessment of and advice on footwear – A podiatrist will often work in conjunction with a few shoe shops, usually the ones they know have well trained staff and that have a great range of high quality shoes for different applications.
- Stretching and strengthening exercises – it is important that you have been assessed to ensure that the weaker muscles are being strengthened and the tight muscles are being stretched.
- Dry needling into trigger points – several practitioners are competent in performing this including some podiatrists, some physiotherapists, and some massage therapists.
- In-shoe padding and support – this can be provided by your podiatrist and is quite low cost ($20-100) using semi-compressed felt, or more permanent materials such as EVA and poron.
- Soft tissue massage.
- Ask when booking if your therapist is trained in dry needling (Dynamic Podiatry has podiatrists trained and regularly practising this modality).
2. Achilles Tendinopathy:
What is The Achilles Tendon?
The Achilles tendon connects the strong calf muscles (gastrocnemius and soleus) to the back of the heel bone.
Together with these muscles the Achilles is one of the biggest drivers of forwards motion such as walking, running, and jumping.
It is used to transfer energy from the muscles to plantarflex the foot (like when you go up on tip toes) which is a crucial part of propelling the body forward during running and walking.
It also drives the pedals when cycling and gives you power in a freestyle swimming kick.
So, it stands to reason that such a strong piece of anatomy that is used constantly can be involved in injury.
There are several types of Achilles Tendinopathies (tendinopathy is the umbrella term).
Here are some of the most common pathologies involving the Achilles Tendon:
1. Mid portion Achilles Tendinopathy:
Mid portion Achilles tendinitis is an inflammation of the Achilles tendon between where the muscle ends and the heel bone insertion begins.
It can be caused by a sudden injury where the foot or ankle is twisted or flexed further than it is capable of withstanding. Or it can be caused by overuse injury often related to over-training.
When the Achilles tendon becomes inflamed, usually from micro tears in the fibres, swelling occurs.
Because the tendon has a sheath that it runs through like a conduit, swelling causes compression in the sheath and increases the friction, making it painful to move the tendon within the sheath, which is crucial to ambulation (walking or running).
2. Insertional Achilles Tendinopathy:
– occurs where the tendon “inserts” into the back of the calcaneus (heel bone).
The main causes of insertional Achilles tendinopathy include:
– Retro calcaneal bursitis – this is an inflammation of the anatomical bursa which sits between the heel bone and the Achilles Tendon just before the insertion into the heel bone.
Anatomical bursas are small fluid filled sacs that act as a shock absorber and absorb friction and stress.
Unfortunately, there is a limit to how much stress they can absorb before they become inflamed themselves and cause pain. Over time they may ossify (become bony) and form what is called a Haglund’s deformity.
– Retro Calcaneal Enthesopahthy – a more common term for this is heel spur. A posterior calcaneal heel spur grows from the insertion of the Achilles tendon at the bone -along the tendon itself.
3. Retro Calcaneal Enthesopathy or Heel Spur:
At the point where the Achilles tendon joins (inserts into) the calcaneus (heel bone), a bony spur can form.
This happens when there is enough irritation and inflammation at the point of insertion that new bone growth is stimulated (osteogenesis).
This causes a bony spur to grow up into the Achilles tendon itself.
Unlike with plantar fasciitis, the spur at the back of the heel can actually cause pain itself (in plantar fasciitis bony spurs can occur, but are not the source of the pain).
The spur will then cause pain when the tendon is under strain, especially torsional load.
Once the inflammation is settled however, the pain tends to resolve even though the spur will remain and is still visible on X-ray.
In fact we see many patients with a posterior heel spur who cannot recall having an Achilles or heel problem.
Treatment of Achilles Tendon Pain:
Podiatrists will take a detailed history before assessing biomechanics of the patient including tightness of muscles, strength of muscles, alignment, ranges of motion, and gait to determine the most likely cause of the injury.
This can then be addressed and will nearly always have an exercise component.
Tendons don’t like to be still for long and will tend to degrade without loading. So, getting you loading your injured Achilles in a safe manner is very important.
Further treatments may include footwear changes, in-shoe heel raises, modification of activity, foot orthotics, needling and massage.
Achilles injuries can take up to 3 months to fully settle after treatment begins, so it’s important to get seen as early as possible.
Tendons Hate Rest!
This has been a crucial finding in getting people with Achilles tendon pathology (and any tendons in the body for that matter)!
Tendons hate rest and will actually decay for as long as they are not loaded.
By setting up a stepped loading program, very carefully tailored for each individual, their activities and goals, we are able to help you create great strength in an injured tendon and get you back to your favourite activity pain free.
Tailored to YOUR Activities and Goals
So if you’re someone who plays netball, AFL, soccer, rugby league or union or any other sport where you need to move sideways quickly, then that will be built into your program.
If you’re someone who loves walking and wants to build up to walking more trails, then strength for rough terrain will be built in, and if you want to sprint, then ballistic movements will be built into your program.
Further treatments may include footwear changes, in-shoe heel raises, modification of activity, foot orthotics, needling and massage.
Achilles injuries can take up to 3 months to fully settle after treatment begins, so it’s important to get seen as early as possible
Other Causes of Heel Pain:
3. Tarsal Tunnel Syndrome:
You may have heard of carpal tunnel syndrome, a condition which causes pain , tingling and numbness in the fingers and thumb due to compression of the median nerve. Often caused by repetitive work using the hands and wrist.
Tarsal Tunnel Syndrome is the lower limb equivalent of carpal tunnel syndrome.
The nerve on the inside (medial) of the ankle (tibial nerve).
4. Baxter's Nerve Impingement:
Similar to tarsal tunnel syndrome Baxter’s Nerve Impingement is caused by compression of the lateral plantar nerve which runs along the medial of the ankle and can often mimic plantar fasciitis.
Some researchers have quoted Baxter’s nerve as the cause of 20% of all heel pain.
This would make it the third largest cause of heel pain after plantar fasciitis and Achilles tendinopathy.
5. Stress Fracture of the Calcaneus (Heel Bone):
Stress Fracture of the calcaneus or heel bone occurs when excessive stress on the bone exceeds the bones natural ability to repair itself.
This causes tiny cracks in the bone over time which eventually become a full fracture as bone tissue continues to be broken down.
This can either be caused by osteoporosis (decrease in bone density) which is the result of low calcium, age, malnutrition, or hormonal imbalances.
It is a condition which requires immediate off-loading with a aircast boot (moon boot) and can take several months to fully heal.
Stress fractures can sometimes be diagnosed on plain X-ray but will often require a nucleotide bone scan or CT scan.
Some Less Common Causes of Heel Pain are:
- Haglund’s deformity
- Osteomyelitis (bone infection)
- Peripheral neuropathy (usually related to Diabetes or following Chemotherapy).
- Paget’s disease
- Sarcoidosis (collections of inflammatory cells in the body)
- Reactive arthritis
- Rheumatoid arthritis
- Bone Tumor
We Take the Time to Ensure Fast Recovery:
At Dynamic Podiatry we take the time to fully assess you condition by taking a full history of you condition including activities, injuries and any other complicating factors.
Then we use our experience and technology to fully assess your biomechanics in gait and stance, functional testing, strength testing and range of motion so that we know which parts need strengthening, stretching or support.
We then tailor a recovery plan to fit into your lifestyle and get you back to full activity pain free.
Prevention is Better Than a Cure:
Although these heel pain conditions involve different tissues surrounding the heel, they are all part of the same chain, and therefore there are some things that you can do to make you less likely to get them.
Here are a few simple measures you can take to prevent getting heel pain:
- Exercise your legs daily – all these tissues are vascular (they are nourished by the blood stream), so getting some exercise into them each day will help to keep them supple and strong. We are starting to realise more and more that exercise is one of the best methods of prevention of injury and rehabilitation.
- Wear supportive trainers (running shoes) with orthotics if you have been prescribed them. Trainers will hold your feet in a supported position and put less tension on your Achilles tendon and plantar fascia because of the heel height.
- Stretch before and after exercise. Simple calf stretches can help to reduce the amount of tension in your Achilles tendon, and in the intrinsic muscles of you foot (tolerant more about the intrinsic foot muscles, head to our blog post here).
- Keep your weight at a healthy level. As mentioned earlier, we understand that if you already have a sore foot, it is hard to exercise to get your weight down, this is when you may need some help from a Podiatrist. You can book an appointment online by clicking the button below or call 3351 8878.
- Drink plenty of water. Sounds a bit of a long bow? Dehydration has an affect on all of the tissues in your body, drying it out and making it more susceptible to injury.
We Want to Get You Back to Being You:
At Dynamic Podiatry our whole philosophy is directed at getting you back to the person you were before heel pain.
We work with you and your lifestyle to develop a treatment plan to get you back to all the activities you enjoyed before, without pain.
Our experience in helping people like you has allowed us to hone our diagnostic and treatment skills to ensure the best results.
Further, we use the latest technology for both our diagnosis and treatment.
To make an appointment call 3351 8878 or click on the button below.