The Common Causes of Heel Pain
There are various reasons why you may suffer from pain in your heel. Although the most common cause is plantar fasciitis -- also known as heel spur syndrome -- other causes can range from a simple stress fracture to a bony enlargement on the back of your heel called Haglund’s deformity.
Before you can get rid of the heel pain, you must know the common causes of the pain, how it occurred, and what treatments are available. An experienced podiatrist, like the ones at NEPA Podiatry, can help diagnose the root cause of your pain and provide a treatment option that works best for your issue.
Heel pain is one of the most common complaints in the foot. The most common form of heel pain is Plantar Fasciitis. Plantar fasciitis is associated with the presence of a heel spur. Pain from a plantar heel spur is rare and is often mistakenly blamed for the heel pain. Most plantar heel spurs do not need to be removed to relieve pain.
What is Plantar Fasciitis?
As body weight is placed over the foot, the arch lowers acting as a natural shock absorber. When the arch lowers, the foot lengthens slightly. This causes the band to the bottom of the foot to stretch and pull tight. When the attachment of this band on the bottom of the heel gets damaged or inflamed, this stretch becomes painful and plantar fasciitis occurs.
What are the symptoms of Plantar Fasciitis?
The hallmark symptom of plantar fasciitis is intense pain on the bottom of the heel most notably with the first steps of the day or first steps following extended periods of inactivity. The pain usually improves after a few minutes of walking. Despite the improvement after walking, the initial pain can be quite intense.
What are the Treatment Options for Plantar Fasciitis?
Plantar Fasciitis is considered a self-limiting condition. That is plantar fasciitis can go away without treatment but it can take up to a year to resolve. Many seek treatment to relieve pain as it can get quite painful. Treatments can be categorized into 3 major modalities, mechanical modalities, anti-inflammatory modalities, and procedural modalities.
- Rest. Decreasing or even stopping impact activities that make the pain worse is the first course in reducing the pain. You may need to stop athletic activities where your feet pound on hard surfaces, for example, running or step aerobics.
- Ice. Rolling your foot over a cold water bottle or ice for 20 minutes is effective. This can be done 3 to 4 times a day.
- Exercise. Plantar fasciitis is aggravated by tight muscles in your feet and calves. Stretching your calves and plantar fascia is the most effective way to relieve the pain that comes with this condition.
- Calf stretch: Lean forward against a wall with one knee straight and the heel on the ground. Place the other leg in front, with the knee bent. To stretch the calf muscles and the Achilles tendon, push your hips toward the wall in a controlled fashion. Hold the position for 10 seconds and relax. Repeat this exercise 20 times for each foot. A strong pull in the calf should be felt during the stretch.
- Plantar fascia stretch: Wrap a belt or towel around your toes to help pull your toes toward you. Hold the stretch for 10 seconds. Repeat it 20 times for each foot. This exercise is best done in the morning before standing or walking.
- Supportive shoes and orthotics. Supportive shoes like running shoes support heel position and help with shock absorption. Custom molded orthotics are inserts that go into shoes that help to support the foot arch to reduce the strain on the plantar fascia. Often, mold orthotics are covered by insurance. Orthotics are often recommended to patients after the problem resolves as it helps to reduce the likelihood that the problem will return.
- Night splints. A night splint passively stretches the plantar fascia while you sleep. Although it can be difficult to sleep with, a night splint is very effective and does not have to be used once the pain has resolved.
- Physical therapy. Your doctor may suggest that you work with a physical therapist on an exercise program that focuses on stretching your calf muscles and plantar fascia. In addition to exercises like the ones mentioned above, a physical therapy program may involve specialized ice treatments, massage, ultrasound, and medication to decrease inflammation around the plantar fascia.
- Extracorporeal shockwave therapy (ESWT). During this procedure, high-energy shockwave impulses stimulate the healing process in damaged plantar fascia tissue. ESWT has not shown consistent results and, therefore, is not commonly performed.
Oral or topical anti-inflammatories are a mainstay in the treatment of plantar fasciitis. Over-the-counter anti-inflammatories like Ibuprofen, Naprosyn, or Voltaren Gel are often used but must be used with care as many patients have medical conditions or medications that can cause unintended side effects. Extended use of anti-inflammatories must be supervised by a physician.
- Cortisone injections. Cortisone, a type of steroid, is a powerful anti-inflammatory medication. It can be injected into the plantar fascia to reduce inflammation and pain. Your doctor may limit your injections. Multiple steroid injections can cause the plantar fascia to rupture (tear), which can lead to a flat foot and chronic pain.
- Alternative forms of treatment: Platelet-rich plasma injections (PRP) or other “stem cell” injections have been used for the treatment of plantar fasciitis with some satisfaction. However, these forms of treatments have not been FDA cleared and are used off-label. These forms of treatment are not usually covered by insurance and can be expensive.
Plantar fascia release. If you have a normal range of ankle motion and continued heel pain, your doctor may recommend a partial release procedure. During surgery, the plantar fascial band is partially cut to relieve tension in the tissue. The surgery can be performed endoscopically and patients are encouraged to walk afterward.
What is Haglund’s Deformity?
Haglund’s deformity is a bony enlargement found in the back of your heel. When this enlargement rubs against the back of your shoes, it causes the soft tissue surrounding your Achilles tendon to become irritated. This leads to inflammation of the bursa, a fluid-filled sac between the tendon and bone.
Haglund’s deformity can form on either foot or both feet. Although heredity plays a large part in the formation of the enlargement, how the foot is structured can make someone more prone to developing the condition, such as:
- High arches
- A tight Achilles tendon
- Frequently walking on the outside of the heel
Symptoms of Haglund’s deformity include a noticeable bump in the back of your heel, pain, swelling, and redness near the inflamed area.
What Treatments are Available?
There are nonsurgical remedies for the condition, mostly aimed at reducing any inflammation to the bursa, including:
- Anti-inflammatory drugs such as ibuprofen to reduce pain and inflammation
- An ice pack to reduce swelling
- Exercising to relieve the tension in the tendon
- Heel lifts placed inside the shoe to reduce the pressure on the heel
- Heel pads placed inside the shoe to reduce irritation when walking
- Physical therapy
- Casting, if necessary
However, to relieve some of the pain, surgery may be needed. It’s important to discuss all your options with your podiatrist to see what treatment plan will work best for your condition.
What Causes a Stress Fracture in the Heel?
Stress injuries usually develop through repetitive trauma, caused by overuse. If left untreated, the injury will become a stress fracture -- a tiny crack in the bone. Stress fractures can be found anywhere in the body but are commonly found in the lower extremities, as a result of impact or weight-bearing activities such as long-distance running.
Depending on the severity of the heel bone fracture, also known as calcaneus fracture, signs and symptoms may include:
- Sudden pain in the heel
- Unable to bear weight on the foot
- Bruising of the heel and ankle
Treatments Available for Calcaneus Fractures
A podiatrist can discuss the best treatment plan with you, which can include the following:
- Rest, ice, compression, and elevation (RICE): Your first course of action is to stay off the foot to allow the fracture to heal. Putting ice on the fracture can reduce swelling, as can compression (such as wearing a compression stocking) and elevation.
- Casting: Putting the foot in a cast or cast boot can immobilize the foot to prevent the fracture from cracking further. Crutches may be needed to avoid bearing any weight on the foot.
- Physical Therapy: Physical therapy can help regain strength and restore function in the heel.
What Is Tarsal Tunnel Syndrome?
Tarsal tunnel syndrome is a compression of the tibial nerve at the inner part of the ankle. Nerve compression can produce symptoms anywhere along the path of the nerve. In tarsal tunnel, the pain can occur at the ankle, the bottom of the foot, and heel or shoot up the inside of the leg and into the knee.
Tarsal tunnel syndrome is similar to carpal tunnel syndrome in the wrist. Both disorders arise from the compression of a nerve in a confined space and are linked to repetitive abnormal motion.
Tarsal tunnel syndrome is caused by anything that produces compression on the tibial nerve. The compression can occur due to anything taking up more space in the tarsal tunnel, closing down of the space, or enlargement of the nerve:
- Things that occupy the tarsal tunnel can range from ganglion cysts, scar tissue, a rare extra muscle, aneurysms, or even bones. The tarsal tunnel has limited room and does not stretch. This causes the tunnel to have less room and the nerve can get squeezed.
- The tarsal tunnel space can be closed down for several reasons. Among the most common reason is a flatfoot. As the foot flattens, the heel rotates inward causing the inside of the ankle to stretch and close down the tarsal tunnel. Additionally, any trauma to the foot and ankle especially injury resulting in fracture can result in the tunnel closing down and squeezing the nerve.
- Tibial nerve enlargement can cause nerve compression in the tarsal tunnel by enlarging so large the tunnel can no longer accommodate the needed space the nerve requires. There are several conditions that can cause this but the most common is diabetes. Diabetic nerve enlargement is especially concerning as this is part of diabetic neuropathy that becomes complicated by nerve compression in the tarsal tunnel. This is known as double crush syndrome and can hasten complications related to diabetic nerve problems.
Patients with tarsal tunnel syndrome experience one or more of the following symptoms:
- Tingling, burning, or a sensation similar to an electrical shock in the foot, heel, ankle, or leg
- Numbness, especially in the foot and toes
- Pain, including shooting, squeezing, or pain that changes in nature. This occurs mostly during activity or at night disrupting sleep.
It is important to seek treatment if any of the symptoms of tarsal tunnel syndrome occur. If left untreated, the condition progresses and may result in permanent nerve damage. In addition, because the symptoms of tarsal tunnel syndrome can be confused with other conditions, proper evaluation is essential so that a correct diagnosis can be made and appropriate treatment initiated.
The foot and ankle surgeon will examine the foot to arrive at a diagnosis and determine if there is any loss of feeling. Additionally, the doctor will hold the foot and tap on the ankle to see if the symptoms can be reproduced. Pressing on the area can help to help determine if a small mass is present.
Advanced imaging studies may be ordered if a mass is suspected or if initial treatment does not reduce the symptoms. Studies used to evaluate nerve problems—electromyography and nerve conduction velocity (EMG/NCV)—may be ordered if the condition shows no improvement with non-surgical treatment.
A variety of treatment options, often used in combination, are available to treat tarsal tunnel syndrome. These include:
- Rest. Staying off the foot prevents further injury and encourages healing.
- Oral medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, help reduce pain and inflammation.
- Physical therapy. Ultrasound therapy, exercises, and other physical therapy modalities may be prescribed to reduce symptoms.
- Injection therapy. Injections of a local anesthetic provide pain relief, and an injected corticosteroid may be useful in treating the inflammation.
- Orthotic devices. Custom shoe inserts may be prescribed to help maintain the arch and limit excessive motion that can cause compression of the nerve.
- Shoes. Supportive shoes are recommended.
- Bracing. Patients with flatfoot may be fitted with a brace to reduce deforming forces on the ankle.
When is Surgery Needed?
The decision for surgery is based on many factors such as the severity of symptoms, EMG/NCV results, and or failure of conservative treatments. Surgery generally consists of cutting of the connective tissue that forms the tunnel. The general goal is to open the tunnel and remove the forces causing nerve compression.
How NEPA Podiatry Can Help
If you are experiencing heel pain, caused by plantar fasciitis, stress fractures, or Haglund’s deformity, NEPA Podiatry is here to help. Schedule an appointment today to learn your treatment options.
This page is for information/educational purposes and does not constitute replacement for recommended diagnosis or treatments.