What should I know about heel pain?

Heel pain is one of the most common complaints of patients with foot and ankle disorders. The pain commonly occurs at the undersurface of the foot called the plantar surface or at the back surface of the heel. While painful heel conditions may not be disabling or cause severe pain, they are typically annoying enough to limit any walking, standing, or running activities. Unfortunately, treatments to rid painful heel conditions can take much time and effort.

Several conditions can cause foot and heel pain. These are described below, as well as symptoms and treatment options.

Plantar fasciitis

Plantar fasciitis is inflammation of a thick fibrous band that extends from the bottom of the heel to the toes (primarily the big toe) called the plantar fascia. It can be very painful, but if treated early, it can be much easier to heal. Common factors that can lead to plantar fasciitis are shoes without adequate support, heavy work demands, obesity, running, and abnormal foot mechanics (the way a person’s feet and ankle move to support the weight of our body).

Symptoms

Pain typically occurs at the underside of the heel and may extend into the arch of the foot. The pain may be sharp at the heel, but typically feels as a generalized soreness or ache in the heel and arch area. Because the inflamed plantar fascia tightens at night, pain is usually the worst at first rising in the morning. This pain may lessen after walking or stretching for a short time as it loosens up. Pain from plantar fasciitis is often made worse by standing, walking, or running. Typically, the presence or absence of a “heel spur” is not significant. Between 30 and 40 percent of the general population has a "heel spur" (on X-ray) and yet, there is no pain.

Treatment

Your physician and physical therapist will determine the best treatment for you. Generally, for mild, non-chronic cases, home therapies may be effective. The goals of the following treatment approaches are to decrease inflammation and pain, increase flexibility, reduce excessive stress on the plantar fascia, and promote healing of the fascia.

  • Tape the arch of your foot (typically done by a physical therapist or athletic trainer).
  • Pad your heel (for comfort).
  • Use an in-shoe orthotic device -- this may be an over-the-counter or custom device prescribed by a podiatrist, physician, or physical therapist -- to keep the foot stable and control excess foot motion.
  • Inject cortisone shots into the heel area.
  • Take anti-inflammatory medicine (by mouth, for 2 to 3 weeks.) Examples of anti-inflammatory medicines are aspirin, ibuprofen (Advil®, Motrin®), and naprosyn.
  • Massage with ice. Fill a paper cup ¾ of the way with water and freeze it. Peel away the upper portion of the cup to expose the ice. Apply the ice directly to the heel and arch area and move around in a circular fashion for approximately 5 minutes or until the skin feels numb.
  • Change your shoe gear. Buy shoes that provide adequate support for your feet and especially those made for specific activities. (Your physician or physical therapist may guide this.)
  • Perform physical therapy to include stretching (Achilles tendon and calf muscles), strengthening, and use of anti-inflammatory methods, including ice, ultrasound, or iontophoresis. Iontophoresis is a treatment that uses an electric current to deliver dexamethasone to the affected area to reduce inflammation.

Heel cord stretching is one of several important treatment options for heel pain.

  • Use a night splint (a type of brace that holds the foot and ankle in the proper position and provides a light stretch of the Achilles/calf).
  • Wear a walking boot for 3 to 6 weeks. (A walking boot, a type of boot that supports the foot and ankle after injury.)
  • Surgery (rarely necessary).

Achilles tendonitis

The Achilles tendon is the largest and strongest tendon in the body. The Achilles connects the calf muscles to the heel bone. The tendon allows us to walk, run and jump. Achilles tendonitis is an inflammation of the tendon and is almost always caused by overuse.

Any activity that requires a pushing off, such as basketball or running, can result in tendonitis. If Achilles tendonitis is left untreated, the condition may progress to Achilles tendinosis, which is a chronic degenerative condition of the Achilles tendon without signs of inflammation. This condition is more difficult to effectively treat.

Symptoms

Symptoms include pain and stiffness in the back of the ankle close to the heel, especially when walking and bearing weight. There could also be mild swelling along the tendon. Chronic tendonitis (lasting more than 6 weeks) can lead to tendinosis and, in severe cases, rupture of the tendon may occur.

Treatment

Your doctor and physical therapist will determine the best treatments for you. The following are common treatment approaches for Achilles tendonitis:

  • Rest. Remain inactive until symptoms have lessened, then gradually return to activity.
  • Orthotics. Wedges, heel lifts, and stable shoes will help correct muscle imbalances caused by repeated movements, which are considered a main contributor to Achilles tendonitis
  • Medications. NSAIDS (non-steroidal anti-inflammatory drugs) increase healing strength.
  • Stretching. Once the pain has lessened, stretching is one of the most important treatments for Achilles tendonitis. Stretch as far as possible until tightness is felt. If stretching becomes painful, then you are pushing too far. Wall leans (remain flat footed with knee fully extended and your foot pointed slightly inward, then lean toward the wall, slowly stretching the calf muscles and Achilles tendon) are a good way to stretch the Achilles tendon.
  • Rehabilitation (strengthening) exercises. Strengthening exercises help to restore normal strength, endurance, and capacity of the Achilles to tolerate activity. These exercises are progressed gradually from pushing against an elastic band, to progressive toe raises emphasizing lowering very slowly (eccentric lowering). Other exercises such as balance training, functional exercises like squats, step-downs, and lunges may also be helpful.
  • Shock wave therapy. Shock wave therapy (strong sound waves) may be tried to reduce pain and promote healing of this condition. This type of energy wave treatment is often tried before surgery.
  • Surgery. If symptoms have not lessened after 6 months of non-surgical treatments, surgery to repair the damaged tendon becomes an option.

Calcaneal bursitis

Bursitis means an inflammation of a bursa, a sac that lines many joints and allows tendons and muscles to move easily when the joint is moving. In the heel, bursitis may cause bruise-like pain usually at the back of the heel. This pain is most often felt at the end of the day, especially for people who spend much of their time on their feet.

Besides pain, the common symptom of calcaneal bursitis is a baggy swelling on the back aspect of the heel. There is no arch pain with this condition.

Treatment

  • Ice
  • Heel cups/cushions
  • Cortisone shots
  • Physical therapy
  • Anti-inflammatory medications

Calcaneal apophysitis (Sever's disease)

In this condition, the growth plate in the back of the heel becomes irritated as a result of a new shoe or an increase in athletic activity. This pain occurs in the back of the heel, not the underside of the heel. This condition is a frequent cause of heel pain in active, growing children between the ages of 9 and 12. Although almost any boy or girl can be affected, children who participate in sports that require a lot of jumping have the highest risk of developing this condition.

Treatment

The most common treatment options for calcaneal apophysitis include:

  • Heel lift
  • Stretching of the calf muscles
  • Ice
  • Anti-inflammatory medications
  • Orthotics (uncommon)

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