The most common heel pain is due to a condition called plantar fasciitis. The pain that occurs with this disorder is typically noted directly under the heel, the pain is quite severe upon initial ambulation after rest. Most people, but not all, experience a sharp stabbing pain with the first step in the morning, which eases slightly with walking. The pain is typically worse the day following strenuous exercise or long hours on the feet. Many people find as long as they remain very active they are fine, but once they relax, put their feet up and rest, they have difficulty standing again.
The cause of this pathology is due to a thickening of the band of connective tissue called the aponeurosa, which extends from the heel to the base of the toes. Normally the band acts like a thin rubber band flexing with each step, but if the band thickens at the attachment to the heel it loses its ability to stretch. With rest the band contracts, so when a person resumes activities this fascial band, which has thickened and is tight feels like it is ripping with each step. The pain is due primarily to micro-tears within the tissue and severe irritation to the area of the heel bone where it is attached. Most people find once they become active the band stretches out and is no longer as sensitive. With time it takes longer to alleviate the problem with walking. Furthermore, overtime the problem escalates and occurs throughout the day. If left untreated the ankle, knees and lower back can become painful.
Treatment can be as simple as a change in shoes or as complex as surgery. Typically, at our office we take x-rays to determine if there are any bone changes, fractures, tumors or spurs. We then measure the thickness of the band at the attachment to the calcaneus (heel bone) via Ultrasound, comparing the non-symptomatic foot to the symptomatic foot. Normally the band measures between 3mm to 4mm in thickness. Depending on our findings and the extent of the pain we might measure for functional orthotics, place the patient in a splint to help stretch the band, immobilize the area, prescribe oral or topical anti-inflammatories, initiate Laser therapy to reduce the pain, do a cortisone injection, apply a strapping of tape, or send the patient for blood work to rule out high levels of uric acid, arthritis, infection or some type of systemic disorder. Each patient is unique therefore treatment needs to address not only their pain but their life style.
If you or a loved one is experiencing this type of pain please see a podiatrist as soon as possible, the earlier this condition is addressed the easier it is to reverse. If you have been to a doctor and either still have the pain, or you did not like the treatment they offered, then it may be time for another opinion.
Heel spurs are boney protrusions on the underside of the heel and are not the cause of the heel pain. Pain is most likely from the thickening of the plantar fascial band which can occur with or without a spur formation. So stop worrying about the heel spurs, many people have them, some are inherited and some may occur due to the constant tension from the plantar fascial band of the heel at its insertion. Before the advent of ultrasound to measure the thickening of the fascia, it was widely believed the heel spur was the sole cause of the pain the heel. This is a myth which has been repudiated over the years by overwhelming proof. So if you still believe your pain is from heel spurs and only surgery can correct the problem, you have been sadly mislead. Actually if a surgery is performed that only removes the spur without addressing the fascial band then it will probably fail. Over the years I have performed probably a thousand heel surgeries and I only smooth the tip of the spur, I never remove the entire spur since this would only cause additional pain for the patient to endure and rarely, if ever is needed to reduce the heel problem.
Tarsal Tunnel Syndrome
This condition is similar to carpal tunnel syndrome but occurs in the foot. A nerve called the Posterior Tibial nerve becomes entrapped in fibrous tissue. When this nerve becomes compressed or squeezed a burning sensation may occur. This burning may radiate into the ankle, numbness or tingling can spread over the heel and arch area, and shooting pains into the remaining foot or lower leg can occur. Anyone who has ever suffered with a pinched nerve knows the severity of the pain that can ensue. When this occurs in a foot the pain can be excruciating.
Treatment may vary depending on related biomechanical changes, nevertheless, functional orthotics, ankle supports, injections, Laser Therapy, immobilization, oral and topical medications and possible surgical intervention may be required to alleviate this painful disorder.
Achilles Tendonitis, Bursitis and Haglunds Deformity
The Achilles tendon is comprised of the soleus and the two heads of the gastrocnemius muscles that merge at the back of the heel and form the largest tendon in the human body. A tendon is a tough band of fibrous connective tissue that connects muscle to bone. The Achilles, also called the Tricepts Surae, is one of the most often injured tendons in the body. It has been known to rupture during a sports injury, but most often it becomes inflamed due to overuse, exercise or from wearing a negative heel shoe. Shortening of the Achilles tendon called equinus can occur from years of living in high heels, from a birth defect such as a clubbed foot, or it just may be an inherited trait. Heel Bursitis or retrocalcaneal Bursitis is a condition that occurs at the back of the heel when the fluid-filled sacs called the bursae, which act as lubricating cushions between the Achilles tendon and the heel bone, become irritated from repetitive actions or overuse. This condition presents as a localized area of redness and swelling that may be warm to the touch. It often is seen in conjunction with Achilles Tendonitis. Haglund’s Deformity, a condition which was once called a “Pump Bump”, is basically a spurring or boney protuberance of the posterior aspect of the calcaneus. In simple terms it is a bump at the back of one’s heel. The enlargement of the bone in this area becomes tender to the constant pressure of a closed-in shoe. This condition is often inherited. The bump may actually increase in size with repeated irritation to the area
Symptoms of Achilles tendonitis may include mild pain after running or walking that gradually worsen, mild to severe pain to touch at the back of the heel, pain may run along the entire tendon into the back of the leg or may be localized to back of the heel. Often there is some swelling, morning tenderness or stiffness that eases with walking. Pain can be severe when the tendon is squeezed.
Treatment for Achilles tendonitis or bursitis usually requires several steps depending on the severity of the pathology. Radiographs will determine if there is an osseous (boney) component and Ultrasound will determine if there is a tear in the tendon. If the tendon is torn then surgery may be required. If the tendon is inflamed and there is small tears or edema within the tendon then immobilization is usually required. If the problem is just beginning and not severe then proper shoes, inserts or orthosis may be prescribed as well as proper stretching. When the area is so inflamed and tender that the patient is unable to walk, wear a shoe, or have any pressure at all on the site, then a topical or oral anti-inflammatory, injections, medicated bandages, or a myriad of other treatments including Laser Therapy may be required. I have found that reducing pain in the Achilles Tendon is usually comprised of a series of steps; first we have to alleviate the pain completely usually with a medicated bandage, immobilization and occasionally injections or Laser therapy. After pain is gone we place the patient in a less constricting brace and slowly introduce more strenuous activities. If all goes well the final step is usually a specialized insert that is custom made for the individual patient to avoid recurrence of the initial problem. A mild Achilles tendonitis that comes on suddenly is often quickly reversed with the use of MLS Laser Therapy. Treatment for a Haglund’s Deformity may be as simple as wearing backless shoes, adding heel pads to lift the foot so the boney area does not rub, or surgery to remove the enlargement permanently.
Sever’s Disease (Pain in Children’s Heels)
This is a condition called Calcaneal Aphophysitis that occurs when there are microtraumas to the growth plate that is located on the back of the heel. In a growing child the posterior aspect of the calcaneus has not become fused with the main body of the bone because the heel is still in the process of maturing. Children that participate in a variety of athletic activities can experience microtraumas to this growth plate which will cause inflammation and pain in the heel. Children as young as 6 and as old as 16 can experience this problem, they will complain of heel pain during or after engaging in a sport, they may be limping or having difficulty walking, the pain will subside after rest but returns with activity.
Treatment for this problem is usually deep seated functional orthotics that can be moved from one shoe to the next and worn especially while engaging in the activity that preceded this condition. Children should be encouraged to participate in sports and physical activities, heel pain should not restrict their activities. If your child is complaining of heel pain when they have been active immediate treatment should include ice, elevation and children’s Ibuprofens, but the problem will get worse without professional evaluation and treatment. It is very important to have your child evaluated by a foot doctor that treats both children and sports related problems. At our office we offer a customized functional orthosis that was created for this type of pathology, it allows your child to remain active and pain free.