Heel Pain Causes And Treatments
Heel pain in Adults is relatively common. There are a number of different causes for heel pain and therefore a number of different treatments. The solution to your heel pain will depend on the type of pain, and its’ underlying cause. There are types of heel pain which are common to all ages, genders and sporting activities. Other causes of heel pain are specific to a particular age, activity or medical condition.
Our Orthopaedic Podiatrist, Chris Parish, has more than 2 decades of experience diagnosing and treating heel pain. To discuss your heel pain in more detail, or to make an appointment to see Chris about pain in your heel, please contact us by phone, email, or using the online contact form.
Contents
- Plantar Fasciitis in Adults
- Treatment for Plantar Fasciitis
- Long Term Heel Pain In Adults – Chronic Plantar Fasciitis
- Extracorporeal Shockwave Therapy (ESWT)
- Benefits Of ESWT
- Subcalcaneal Bursitis
- Treatment Of Subcalcaneal Bursitis
- Calcaneal Fractures
- Treatment For Calcaneal Fractures
- Calcaneal Stress Fractures
- Treatment For Calcaneal Stress Fractures
- Loss Of The Fat Pad Of The Heel
- Treatment for Loss of the Fat Pad of the Heel
- Achilles Tendonitis (Tendinitis) and Paratendonitis (Peritendinitis) in Adults
- Treatment for Achilles Tendonitis (Tendinitis) and Paratendonitis (Peritendinitis)
- Haglund’s Deformity
- Treatment For Haglund’s Deformity
- Traumatic Arthritis
- Treatment For Traumatic Arthritis
- Tarsal Tunnel Syndrome
- Treatment for Tarsal Tunnel Syndrome
- Gout And Associated Heel Pain
- Treatment For Gout And Associated Heel Pain
Heel Pain Causes And Treatments
Plantar Fasciitis In Adults
The plantar fascia is a ligament-like structure which runs from the bottom of the heel bone (the calcaneus) to the front of the foot (see picture to the right). Plantar fasciitis – inflammation of the plantar fascia – is one of the most common causes of heel pain in adults. It occurs when excessive strain is placed on the plantar fascia usually as a result of poor foot function: either a flat foot (over-pronation) or a high arched foot (over supination). Jumping or prolonged standing can also cause increased tension.
The most common symptom of plantar fasciitis is pain beneath the heel and sole of the foot. The pain is often worse when stepping onto the foot, particularly when first getting out of bed in the morning or getting up after being seated for some time.
Treatment For Plantar Fasciitis
Once your heel pain has been assessed by an Orthopaedic Podiatrist, they will determine the cause and any appropriate treatment. Some rest is usually advisable; excessive and repetitive heel impact from jumping and running should be avoided, but a complete lack of physical activity can lead to stiffening and a return of pain, and is not recommended.
The most common treatment will be in the form of custom-made orthotic insoles that fit inside your shoes. These will be custom-made to your foot to help reduce the tension in the plantar fascia while you walk and usually give very good results.
Special splints may be helpful when worn over night, providing pain relief and a gentle stretch.
If the plantar fascia is too tight, stretching excercises can help. Your Orthopaedic Podiatrist will show you how to do this. Additional stretching aids are also available.
If your plantar fasciitis has become long term and seems to have resisted previous treatments, Extracorporeal Shockwave Therapy can be effective for treating chronic plantar fasciitis / heel pain.
Long Term Heel Pain In Adults – Chronic Plantar Fasciitis
Custom-made orthotic insoles that fit inside your shoe can correct poor foot function and help to reduce tension in the plantar fascia while you walk. These often give very good results. However, if your pain is resistant to treatment, or chronic, and your plantar fasciitis has become long term, Swiss Dolorclast®, or Extracorporeal Shockwave Therapy, is often an effective treatment for your chronic plantar fasciitis / heel pain.
Extracorporeal Shockwave Therapy, or ESWT, delivers focused shock waves to the body. This induces microtrauma to the tissue affected by plantar fasciitis, triggering a healing response within the body.
There is both a high-energy and low-energy form of ESWT; and both forms of shockwave therapy can be used in the treatment of plantar fasciitis.
Typically, low-energy shockwave treatments are given as a series of three or more treatments.
Benefits Of ESWT
Benefits include:
- Quick results
- Clinical studies show a 60 – 70% success rate
- Significant reduction in pain
- Improved quality of life
- Outpatient treatment – no need to stay in hospital
- No anaesthesia – no injections
- Non-invasive – no cuts or stitches
- Virtually painless after treatment
Extracorporeal Shockwave Therapy is not yet widely available in the UK, however we have one of the first machines in the UK at Elland Hospital, which allows us to perform this advanced technique.
What will happen when I have this heel pain treatment?
The treatment is fast and effective – the pain is located by touch, a gel is applied to the problem area and the shock waves are delivered to the foot. It is a simple straightforward technique:
- Locating pain by touch
- Marking the treatment area
- Applying the contact gel
- Delivering the treatment – the probe is pressed against the heel
The treatment lasts for 5-10 mins each sitting and 3 to 5 treatments at a weekly interval are normally recommended.
Recovery
Following the procedure, patients are asked to rest and apply ice packs to the treated area for a few hours. Within 24 hours, normal activities can be resumed. Significant pain relief is noted by the majority of patients within 3 weeks of the procedure.
Results
Clinical studies show a 60-70% success rate while using ESWT to treat chronic plantar fasciitis and other tendon problems involving the foot and ankle. Using a VAS 0-10 (Visual Analogue Score: 0 being no pain and 10 being worst pain), 70% of patients report a reduction of at least 5 when asked to score their pain. Full clinical benefits are usually achieved within 2-3 months following treatment.
Patient testimonials:
“Without shockwave therapy, speedy healing would not have been possible.”
– Wolfgang Härle, heel pain patient and Former Cross-Country Skiing World Champion
“I have no more pain and successfully finished the Jungfrau Marathon and the Frankfurt Marathon.”
– Dr. Frieder Katz, heel pain patient, Darmstadt, Germany
“I felt a significant improvement in just three sessions”
Joseph Diebels, heel pain patient.
Expert Opinion
“For the past four or five years I have used radial shockwave therapy in my daily work. I myself suffered a great deal from heel pain and underwent heel spur surgery. After three shockwave treatments, I feel no more pain and can play football again. In fact, I’m training my sons, who want to become professional players.”
Dr. Georgi, Tönning, Germany, physician and heel pain patient
“I’ve been treating heel pain since 1982. The Swiss Dolorclast® method is a great addition to my treatment concept. My success with this unique unit is without equal. Patient comfort and acceptance are excellent. Fortunately, the treatment is so fast and simple that I have never had to use anaesthesia.”
Hartley Miltchin, DPM (Doctor of Podiatric Medicine), Toronto, Canada
References:
Dr. G. Haupt et al., Germany, Radial Shockwave Therapy for the treatment of heel spur (Plantar Fasciitis). Journal “Der niedergelassene Chirurg”, No. 30. 2002. Dr. Lohrer, Sportmedizinisches Institut, Frankfurt (Germany).
Dr. L. Gerdesmeyer / Dr. L. Scott Weil et al. Summary of Clinical Study Results / FDA – PMA Approval,
Treatment of painful heel, May 2007
Subcalcaneal Bursitis
Subcalcaneal bursitis refers to inflammation of the sack of fluid (the ‘bursa’) under the heel. This is called ‘bursitis’.
The bursa becomes inflamed when there is excessive movement of the heel bone (the calcaneus), when walking. When we walk our feet have a tendency to roll inward, toward each other, in a motion we call pronation. When feet pronate too much, the heel bone rubs repeatedly against the bursa and causes friction. This leads to pain and inflammation.
Classic symptoms of subcalcaneal bursitis include pain and a feeling of stiffness in the bottom and/or side of the heel. The pain is often sharp and deep, similar to the pain experienced when stepped on a stone or nail. It can occur when standing and walking after sitting for a prolonged period of time.
Treatment Of Subcalcaneal Bursitis
Once your heel pain has been assessed by an Orthopaedic Podiatrist, they will discuss appropriate treatment options with you.
The most common treatment will be in the form of custom-made orthotics, insoles that fit inside your shoes. These will be tailored to your feet and will help to reduce the excessive movement of the heel while you walk.
Supportive shoes, especially if you’ve recently increased your activity level, controlling your body weight and maintaining overall flexibility can help to prevent a recurrence of the problem.
Calcaneal Fractures
A calcaneal fracture (broken heel bone) is the name given to a fracture, crack or break in the calcaneus (heel bone). Calcaneal fractures are almost always caused by a one-off impact and occur usually as a result of jumping or falling from a height. They are different from calcaneal stress fractures which occur through repetitive strain.
Calcaneal fractures cause significant swelling and pain at the back of the foot. Typically symptoms include inability to walk, swelling and bruising of the foot and severe heel pain. Most calcaneal fractures are closed injuries, meaning the skin is intact. When the skin around the calcaneal fracture is broken, this may represent an open or ‘compound’ fracture, which is a surgical emergency. If you suspect this, go straight to hospital.
Treatment For Calcaneal Fractures
Once your foot has been assessed by an Orthopaedic Podiatrist, they will discuss appropriate treatment options with you. Calcaneal fractures are generally quite severe injuries but most do not require surgery. If the calcaneal fracture is not out of position, a cast and crutches will probably be recommended. Patients will be required to keep weight off of the foot for as long as three months.
It is also important to control any swelling. The best ways to do this is elevating the foot, complete rest and applying ice through a tea towel.
If surgery is necessary, a metal plate and screws may need to be placed into the broken heel bone. Your Orthopaedic Podiatrist will recommend the appropriate treatment based on your particular fracture.
All patients with a calcaneal fracture should also be examined for other high-impact injuries as studies suggest that a large number of patients with a calcaneal fracture also have fractures of the lumbar spine (10 to 15%).
The recovery period of a calcaneal fracture usually determines how well a patient will return to his pre-injury level of activity. It is likely that you will need custom-made orthotic insoles in your shoes to help prevent a reoccurrence of the fracture.
Calcaneal Stress Fractures
A calcaneal stress fracture is the name given to a very small, hairline fracture or crack in the calcaneus. The calcaneus bone is the big heel bone at the back of the foot. In contrast to calcaneal fractures and other types of fracture or breaks that are caused by a one-off impact, a calcaneal stress fracture is caused by repetitive stress.
Stress fractures can occur in any bone in the body but are quite common in the weight-bearing bones of the foot. There is often no recollection of injury and most cases are associated with sports injury and overuse. Soldiers, for example, who do a lot of marching, runners and ballet dancers, are particularly prone.
Calcaneal stress fractures can sometimes be difficult to diagnose. The heel pain is usually gradual but made worse for weight-bearing activities, and can be reproduced by squeezing the back of the heel from side to side.
Treatment For Calcaneal Stress Fractures
Often an X-ray of the injured bone will not show any sign of fracture until the stress fracture has already started to heal some 2 to 3 weeks later. It is also possible that a stress fracture will not appear on an X-ray at all.
Your Orthopaedic Podiatrist will examine your foot and ask about your usual routine and physical activities. This will help him to determine how the fracture occurred and more importantly, how to prevent another one from happening. One question he will try to find the answer to is “Why did it happen to this foot and not the other?” This is quite often due to a small deficiency in the function of the foot which your Orthopaedic Podiatrist can diagnose.
Resting the injured leg is usually always recommended. If there is nothing to suggest the stress fracture may get worse, then simply avoiding the ‘overuse’ activity may be sufficient.
Severe calcaneal stress fractures may require the use of crutches and possibly a plaster cast. It is likely that you will need custom-made orthotic insoles in your shoes to help prevent a reoccurrence of the fracture.
Loss Of The Fat Pad Of The Heel
Loss of the fat pad or fat pad atrophy refers to a thinning of the protective fat pad cushion on the bottom of the heel or ball of the foot. Made primarily of fatty, shock-absorbing tissue, we rely on these pads to cushion our bones and disperse our body weight from the impact we make when we land on them.
Heel pain due to a loss of the fat pad of the heel is more likely to occur in later life as the fat pad layer thins with age. Insufficient cushioning causes bruising to the heel as our body weight is borne by a much smaller, bony-hard and more concentrated area.
Typically pain is experienced in the middle of the heel, in contrast to plantar fasciitis, which is felt at the front of the heel. Pain is usually a deep, dull ache that feels like a bruise and pressing your thumb into the centre of the heel should recreate it. Pain is also worse for walking barefoot on hard surfaces like concrete, hardwood floors or ceramic tiles.
Treatment for Loss of the Fat Pad of the Heel
Once your heel pain has been assessed by an Orthopaedic Podiatrist, they will determine the cause and discuss appropriate treatment options with you.
The most common treatment will be in the form of custom–made orthotic insoles that fit inside your shoes. These will be tailored to your foot and will help to cushion your heel and control your foot as you walk. Heel cups can sometimes help. These are plastic cups, usually made from silicone, that surround the heel and support the fat pad under the heel bone. In some, the heel can be suspended completely thanks to a pressure relieving cavity. Heel pads, foam or gel pads that soften the impact at heel strike, can also be added to the shoe for extra cushioning.
It is also important you wear good, well-cushioned shoes whenever possible and avoid hard surfaces while barefoot.
Achilles Tendonitis (Tendinitis) and Paratendonitis (Peritendinitis) in Adults
Achilles Tendonitis refers to inflammation of the Achilles tendon, the large tendon at the back of the ankle that connects the calf muscles to the heel bone. Achilles Tendonitis can be either acute, meaning it occurs over a period of days, or it can be chronic, meaning it occurs over a longer period of time. Generally, Achilles Tendonitis is an ‘overuse’ injury, caused by an increase in physical activity or by engaging in activity without warming up properly first. Running too quickly from a resting position and running up stairs or up a hill can also be factors.
Achilles Tendonitis can also be caused by overpronation (rolling over of the foot), which places extra strain on the Achilles tendon. As the foot rolls in or flattens, it causes the lower leg to rotate inwards, placing twisting stresses on the tendon.
Inappropriate footwear is also a contributing factor, high heels shorten the tendon and calf muscles, and flat running shoes stretch the tendon beyond its normal range.
The most common symptom of Achilles Tendonitis is pain just behind and above the heel, which can range from a short sharp period of pain during or after exercise, or it can be present all the time, particularly first thing in the morning.
Sometimes the skin covering the tendon can become swollen or red and can be very tender to the touch, even producing a squeaking sound or crackling sensation when pressed. This is especially true of Paratendonitis (also called Peritendinitis), which refers more specifically to inflammation of the outer layer of the tendon, the “paratendon”.
Treatment for Achilles Tendonitis (Tendinitis) and Paratendonitis (Peritendinitis)
The immediate treatment for Achilles Tendonitis and Paratendonitis is to rest and restrict movement of the tendon.
Ice therapy can also be applied to help reduce swelling, but never directly to the skin in case of ice burn occurring. Instead, wrap an ice pack in a cloth and apply to the affected area for up to ten minutes; this can also help to numb the pain.
Your Orthopaedic Podiatrist may also recommend custom-made orthotics (prescription insoles) to help correct overpronation and to help prevent excessive movement in the heel, leg and foot. These will be made specifically to fit inside your normal shoes. Measurements will be taken from lines drawn on your heels and a plaster mould will be taken of your feet to capture exact contours and structure. This exact fit is important and enables the insoles to provide maximum results.
The majority of people with Achilles Tendonitis and Paratendonitis benefit from wearing custom-made orthotics. Recovery is fairly rapid and patients may be able to run after two to three weeks providing there is no underlying degeneration of the tendon.
If the patient does not notice any improvement, surgery may be required to remove the paratendon.
Haglund’s Deformity
Haglund’s Deformity is a bony protrusion on the back of the heel. It can occur in one or both feet and often leads to painful “bursitis” (inflammation of the bursa, a fluid-filled sac between the tendon and the bone). In Haglund’s Deformity, the soft tissue near the Achilles tendon becomes irritated when the protrusion rubs against shoes.
Symptoms can include a noticeable bump on the back of the heel, pain in the area where the Achilles tendon attaches to the heel and swelling in the back of the heel. Redness near the inflamed tissue can also occur. People with certain types of foot structure, high arches for example, where the heel bone tilts backward into the Achilles tendon, can be more prone to developing Haglund’s Deformity. The uppermost portion of the back of the heel bone rubs against the tendon and eventually, due to this constant irritation, a bony protrusion develops and the bursa becomes inflamed.
A tight Achilles tendon can also play a role in Haglund’s Deformity, causing pain by compressing the tender and inflamed bursa.
Haglund’s Deformity can also be caused by a tendency to walk on the outside of the heel. This causes the heel to rotate inward, resulting in rubbing of the heel bone against the tendon or shoe. The tendon protects itself by forming a bursa, which eventually becomes inflamed and tender.
Treatment For Haglund’s Deformity
Once your heel pain has been assessed by an Orthopaedic Podiatrist, they will determine the cause and appropriate treatment.
The most common treatment will be in the form of custom-made orthotic insoles that fit inside your shoes. These will be tailored especially to your foot to help control poor foot function while you walk and usually give very good results.
If you do have high arches, heel lifts can help to reduce friction against the tendon and reduce pressure on the heel.
Heel pads placed inside your shoe should also help to cushion the heel and reduce irritation when walking.
Stretching exercises, especially if there is tension in the Achilles tendon, may provide some relief. Your Orthopaedic Podiatrist will show you how to do these. He may also recommend an additional stretching aid, such as splints.
Traumatic Arthritis
Arthritis refers to damage to a joint, causing inflammation. With 33 joints in each foot, you probably won’t be surprised to learn that your feet are especially prone to arthritis.
Traumatic arthritis is a form of arthritis that is caused by either one big injury, or repeated small stresses, to joints which bear a tremendous amount of pressure each day. It can also develop following a bad sprain or fracture to the foot. Symptoms tend to include swelling, pain, tenderness and joint instability.
Treatment For Traumatic Arthritis
Once your pain has been assessed by an Orthopaedic Podiatrist, they will determine the cause and appropriate treatment. The most common treatment for traumatic arthritis will be in the form of custom-made orthotics (prescription insoles). These will help to restrict motion in the foot and reduce heel pain. An exact, custom-made fit is important and enables the insoles to provide maximum results. Measurements will be taken from lines drawn on your heels, and a plaster mould will be taken of your feet to capture exact contours and structure.
Cushioning heel pads that help to protect while you walk may also help.
Tarsal Tunnel Syndrome
Tarsal Tunnel Syndrome is caused by the tibial nerve (the nerve that goes round the inside of the ankle) getting trapped. The tarsal tunnel (tarsal simply means the back of the foot) is found along the inside of the leg behind the ankle bone. The tibial nerve, one of the major nerves supplying the foot, travels with a bundle of other structures (tendons, veins and arteries) through this tunnel. There is very little room for expansion and if any of these structures become enlarged or inflamed, or if anything presses on the small space occupied by the tibial nerve, trapping occurs.
When the trapping compresses the nerve, it causes a painful burning or tingling sensation on the sole of the foot. This is the tibial nerve trying but failing to send signals between the foot and the brain. In many cases, compression is caused by an adjacent muscle that grows too large for the area.
People with exceptionally flat feet (over-pronation) can develop tarsal tunnel syndrome because the flattened arch causes strain on the muscles and nerves around the ankle and changes their route slightly, compressing the tibial nerve.
Another common cause for Tarsal Tunnel Syndrome is trauma to the ankle, such as a broken bone. When the injury heals, fibrous tissue, similar to a scar develops. If too much scar tissue forms, it can restrict movement in the tarsal tunnel and cause entrapment of the nerve.
Treatment For Tarsal Tunnel Syndrome
Your Orthopaedic Podiatrist will confirm Tarsal Tunnel Syndrome following a physical examination of your foot. If the problem is caused by flat feet, custom-made orthotic insoles will help to restore the foot’s natural arch. An exact, custom-made fit is important as it enables the insoles to provide maximum support.
Tarsal Tunnel Syndrome usually responds well to orthotic insoles and extra arch support; however in some instances surgery may be necessary to allow for expansion of the nerve.
Measurements will be taken from lines drawn on your heels and a plaster mould will be taken of your feet to capture exact contours and structure.
If inflammation of the nerve is causing compression, non-steroidal anti-inflammatory drugs (NSAIDs) may be prescribed.
Gout And Associated Heel Pain
Gout is an inflammatory condition caused by a build-up of uric acid in the blood, leading to deposits of uric acid crystals in the joints. The big toe joint is most commonly affected but deposits can also form in the plantar fascia (the ligament-like structure which runs along the bottom of the foot) and can be a cause of plantar fasciitis (heel pain) in adults.
Gout often affects men rather than women and typically men over the age of 50, but it can also occur in younger males and females. Typically symptoms include sudden intense throbbing pain, often in the middle of the night, accompanied by redness and swelling. Attacks can last for up to five days at a time.
Because it is an inflammation response, gout is often referred to as a form of arthritis or gouty arthritis. It is however, different from other forms of arthritis.
Treatment For Gout And Associated Heel Pain
Correct diagnosis is extremely important. Your Orthopaedic Podiatrist will examine your foot and discuss with you your lifestyle and medical history prior to treating you for gout. He may also request an X-Ray of your foot to confirm diagnosis or to gauge how advanced the condition is. If you have suffered with gout for a long time, the X-Ray may reveal some wear and tear of the joint.
A blood test, if taken, may also reveal elevated levels of uric acid in the blood.
To provide immediate relief of symptoms, your Orthopaedic Podiatrist will probably recommend a course of medication from your GP. The most common medication used is called Allopurinal.
For long term improvement of gout, custom-made orthotics – cushioning insoles that fit inside your shoes – can help to reduce pain associated with the plantar fascia and the heel. If gout is confined to the toe area, protective shields and toe pads may be used instead.
Dietary changes can also help. High-protein foods, such as cheese, oily fish, chicken, red meats, shellfish, lentils and alcohol, have all been linked to gout and should be avoided in excess. If you are overweight, losing weight will help. Gout-friendly foods include cherries and pineapple, most berries, fruit and vegetables, brown rice and foods made from corn, rice, potato or buckwheat flours.
Acute attacks of gout are generally treated with a variety of prescription anti-inflammatory drugs. Ice or cooling lotions can also help during an acute phase.
Our Orthopaedic Podiatrist, Chris Parish, has more than 2 decades of experience diagnosing and treating heel pain. To discuss your heel pain in more detail, or to make an appointment to see Chris about pain in your heel, please contact us by phone, email, or using the online contact form.