Heel pain treatment
Heel pain treatment
Heel pain treatment
Heel pain treatment
What causes heel pain?
Heel pain can be an unpleasant experience, particularly if it affects both feet.
The commonest cause of heel pain is plantar fasciitis, but other, less common causes include:
What is plantar fasciitis and how is it diagnosed?
Plantar fasciitis is a common condition that affects the plantar fascia, a thick band of tissue that runs across the bottom of the foot and connects the heel bone to the toes.
The plantar fascia plays an essential role in supporting the foot’s arch and absorbing shock during walking or running. When this tissue is overused or subjected to repetitive stress, small tears can develop, leading to inflammation and pain.
We can usually diagnose a case of plantar fasciitis based on your symptom story and examining your foot. If you have pain in one of both heels on the arch of your foot, that’s worse when you stand up after sitting or sleeping, and if it’s very tender when the area is pressed on, it’s very likely that you have plantar fasciitis. Sometimes it may be necessary to carry out some imaging (e.g. ultrasonography, or MRI scanning) to clarify the diagnosis.
What causes plantar fasciitis?
Plantar fasciitis is a common problem for runners, and it’s more common in women than men. For many very active people, it’s an overload problem, but it can also occur in very sedentary people. It’s the equivalent of an Achilles tendon problem, under the heel, and we know that rather than it being a big inflammation problem, it’s more to do with the breakdown of the collagen-based structure of the fascia.
If you have a particularly tight calf muscles (e.g., because you spend a lot of time wearing heels), this can place stress on the plantar fascia, as can having a very low, or a very high arch foot-type.
If you are a runner with poor biomechanics and your feet overpronate when you run (roll in), or if you have weak intrinsic muscles in your feet, or weak calf muscles, this can lead to overload of the plantar fascia. Gaining weight can also contribute to overload of the plantar fascia.
Worn out footwear, and doing too much too soon, in terms of running and impact activity can also put you at risk of plantar fasciitis.
What about heel spurs?
Heel spurs (sometimes called calcaneal spurs) are little bony projections from the bottom of the heel bones where the plantar fascia attaches. They’re most commonly picked up on an X-ray, but they’re rarely cause of a person’s heel pain, and we should probably think of them as a normal finding on imaging. Many people who have plantar fasciitis will have heel spurs visible on imaging, and it’s probably a traction effect of the plantar fascia on the bone, which produces them.
What is the best treatment for plantar fasciitis?
Stretching the calf muscles and the plantar fascia is the widely recognised as helping plantar fasciitis in the long-term, but you might find it a little uncomfortable in the beginning. A physiotherapist will teach you how to stretch the gastrocnemius and soleus muscles as well as the plantar fascia, and you’ll get the best results if you do this regularly during the day, and even before you put your feet to the floor, first thing in the morning.
If your problem is a weak tibialis posterior muscle, or weak intrinsic, calf or glutes muscles, physiotherapy will help you to address these strength deficits.
Rolling your heel and arch over a cold can or applying ice to your heel after a day at work, may give relief if it’s feeling flared up.
Some patients may also benefit from gait analysis and custom insoles to support the arch.
In recent years there has been compelling evidence for the use of shockwave therapy to treat plantar fasciitis. Shockwave (aka extracorporeal shockwave therapy – ESWT) delivers energy into tissues in the form of sound waves, and it’s delivered by a device held against the tissues. It’s thought that the shockwaves desensitise irritated nerve endings (which reduces pain), and it also creates microscopic trauma to the tissues, which increases blood flow and cellular healing activity in the affected area. In other words, it spurs the body into a new wave of healing.
What about steroid injections?
In the past, steroid injection treatment for plantar fasciitis was commonplace. Whilst steroid injection may give some symptom relief, it tends to be short- lived (just a few weeks), and it doesn’t address the underlying causes. Steroid injections may weaken soft tissues and carry the potential risk of plantar fascial rupture or heel pad atrophy, and they are painful! They are not a first-line treatment and so are only used in extreme cases when all other treatments have failed.
Achilles tendinopathy
Achilles tendinopathy is a degenerative change process caused by repeated microtrauma of the tendon. When it’s in the mid portion of the tendon (aka non-insertional Achilles tendinopathy) it will often respond very well to physiotherapy to load the tendon in a specific way, shockwave treatment, and stretching.
If it’s persistent, you may benefit from an ultrasound guided high-volume injection of the back of the tendon, and very occasionally surgery to lengthen the calf muscle (a medial head gastrocnemius release) may be needed.
Achilles Insertional Tendinopathy
If you have pain in the back of the heel where the Achilles tendon joins the foot, that feels tender, stiff, or swollen, your problem may be an insertional Achilles tendon problem. It’s common in runners, tennis players, and impact sports. In the first instance, I advise patients that it’s worth trying a course of physiotherapy and shockwave to improve their symptoms.
Sometimes insertional Achilles tendinopathy occurs because of a Haglund’s deformity, and if symptoms are persistent, surgery may be required.
Haglund’s deformity
Some people have a pronounced bump on the back of their heel bone, known as a Haglund’s deformity. For many, this causes no problem at all, but sometimes the bony bump can cause painful inflammation in the bursa behind the heel bone, and it can mechanically irritate the Achilles tendon, leading to insertional tendinopathy. The bump can sometimes rub against shoes causing more pain and irritation.
Open Surgery for Insertional Achilles Tendinopathy (with a Haglund’s)
If all attempts to treat this problem conservatively have failed, and the Achilles tendon is damaged at its attachment, a more open surgical procedure may be the best way forward.
This is surgery to partially detach the tendon and tidy up damaged soft tissues, and to remove the Haglund’s bump (if there is one). The Achilles is then firmly re-attached to the heel bone with a ‘speed bridge’. This is often combined with calf-lengthening surgery.
After the surgery, there is a lengthy rehabilitation process. You will start to see improvement from 3 months, but it will take 12-18 months for you to benefit completely.
Minimally invasive surgery for Haglund’s deformity
For some patients, it’s the ‘bump’ of the Haglund’s that causes their problem (e.g. rubbing in their footwear), and if their Achilles tendon is OK, it may be possible to carry out minimally invasive surgery to remove the bump. Patients do really well after this surgery, which has a relatively swift recovery.
