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Heel Pain

It is a very challenging problem as it can be local and/or referred. It has been more prevalent recently due to the hard grounds on which people have to run.

Commonly people will present with heel pain, thrusting an x-ray at you, and being adamant that the problem is a “heel spur”. This is defined as a small bone that grows from the heel, directing forwards towards the toes. This may be as small as 1 mm to anything as large as 8 – 10 mm. Most of the time, this is an incidental finding, as there many heels that are pain free that have heel spurs evident on x-rays. The spur is thought to be a result of traction of the plantar fascia on the heel. In some cases, the spur may contribute to the symptoms, but is not the main cause. This should be explained very carefully to the patient, as the focus on the spur may limit the recovery, as the patient may believe that the only way to eliminate the pain is to remove the spur.

X-rays often show heel spurs which have no clinical relevance.

Heel pain can, like all conditions, can be divided into “common” problems and “uncommon” ones.

The more uncommon conditions that may give rise to heel pain are:

Inflammatory conditions such as ankylosing spondylitis and psoriatic arthritis      characterized by bilateral heel pain;

Reiter’s Syndrome, an inflammatory condition which can occur as sequel to a venereal      infection, can cause asymmetrical intense synovitis, often resulting in a painful heel.      About a 1/3 of these sufferers will also present with a sacro-iliitis.

A local calcaneal tumor or osteomyelitis – if the pain is vague, unresponsive to      treatment and presents with night pain, referral for x-ray and bone scan would be      appropriate.

The more common conditions that may give rise to heel pain are:

Referred pain from the lower back;

Tibial nerve entrapment in the posterior tarsal tunnel;

The most common causes for heel pain are:

Plantar fasciitis

The plantar fascia spans the long arch of the foot from the heel to the base of the toes, where it blends with the soft tissues, then anchoring to the base of the toes.

The plantar fascia - a common cause of heel pain.

As the bony attachment at the heel is considered the plantar fascia’s “weak spot”, the patient will present with pain at the heel, mainly on the inside.

The most common predisposing factor to this condition is the pronating (flattening feet) – 52% - whilst there is also some evidence that a very high arch, in a rigid foot (pes cavus), also was reasonably common – 42%.

Symptoms

Usually worse with the first few steps in the morning or at the initial point of activity. The latter usually gets better with continued activity (squeaky hinge analogy). Walking, running, sprinting, hill running and jumping will increase the pain. Often, the natural response is to walk on the outside of the foot – in supination – to lessen the stress on the plantar fascia – resulting in new problems.

Treatment

Essentially rest from aggravating activity, physiotherapy treatment to alleviate the inflammatory component, stretching the tight calf (Fig 1.), strengthening up of the intrinsic muscles of the foot e.g. tissue scrunch, picking up pens etc. and correction of biomechanical problems in the foot e.g. orthotics. Sometimes, a heel cup or pad to relieve pressure – a donut type pad may be helpful. Strapping has been shown to be helpful, especially in circumstances where the patient can’t wear orthotics – the foot is strapped to help support the arch. There has been limited success with cortisone injections or surgery and the latter is very rarely required.

Fig 1. Calf Stretching for Plantar Fasciitis.

Sever’s Disease

This is a condition that occurs in 10 – 15 year old children, predominantly boys and is associated with running and repetitive jumping. It is also associated with flimsy footwear that kids may wear. It occurs when the Achilles tendon continually pulls on the apophysis of the calcaneum and does not allow for it to fuse with the body of the calcaneum.

    

Sever's Disease - traction apophysitis. Inflammation at the insertion of the Achilles tendon into the calcaneum (heel bone). Associated x-ray findings.

Treatment is predominantly rest and prescription of appropriate footwear.

Calcaneal enthesopathy

This occurs when there is repetitive trauma at the attachment of the Achilles tendon, resulting in a spur from the calcaneum up into the Achilles tendon. It is usually visualized on x-ray and may be tender if there is an associated bursitis or tendonitis.

"Pump Bump"

Also known as Haglund’s Deformity, this is a bony enlargement that exists on the back of the heel – usually related to a congenital abnormality or with chronic bursitis, causing a thickening. There may have already been trauma or pressure from footwear. Treatment is usually protection of the bump and correct footwear.

"Pump Bump" or Haglund’s Deformity.

Retrocalcaneal Bursitis

Associated with a symmetrical swelling at the base of the Achilles tendon. It is usually related to repetitive trauma or inappropriate footwear. It is often red and hot in the early stages. Treatment is usually to correct the footwear, provide padding and treat the local symptoms e.g. ice, rest, physiotherapy and cortisone injection.

Fat Pad Syndrome

Direct contact with the base of the heel may result in trauma to the fat pad. Related to obesity, training on hard surfaces, uneven grounds, poor shoes especially overlarge shoes which can cause shearing forces on the heel. These conditions are renowned for taking a long time to recover – usually many months.