Overview
Heel pain is often a symptom caused by one of two conditions: Plantar Fasciitis or Achilles Tendonitis. Most commonly, heel pain experienced at the bottom of the heel is caused by plantar fasciitis. Heel pain may become so severe for some that just putting weight on their feet first thing in the morning is excruciating. Walking or running may feel completely out of the question.
Causes
To understand the cause of the pain one must understand the anatomy of the foot and some basic mechanics in the function of the foot. A thick ligament, called the plantar fascia, is attached into the bottom of the heel and fans out into the ball of the foot, attaching into the base of the toes. The plantar fascia is made of dense, fibrous connective tissue that will stretch very little. It acts something like a shock absorber. As the foot impacts the ground with each step, it flattens out lengthening the foot. This action pulls on the plantar fascia, which stretches slightly. When the heel comes off the ground the tension on the ligament is released. Anything that causes the foot to flatten excessively will cause the plantar fascia to stretch greater that it is accustom to doing. One consequence of this is the development of small tears where the ligament attaches into the heel bone. When these small tears occur, a very small amount of bleeding occurs and the tension of the plantar fascia on the heel bone produces a spur on the bottom of the heel to form. Pain experienced in the bottom of the heel is not produced by the presence of the spur. The pain is due to excessive tension of the plantar fascia as it tears from its attachment into the heel bone. Heel spur formation is secondary to the excessive pull of the plantar fascia where it attaches to the heel bone. Many people have heel spurs at the attachment of the plantar fascia with out having any symptoms or pain. There are some less common causes of heel pain but they are relatively uncommon. There are several factors that cause the foot to flatten and excessively stretching the plantar fascia. The primary factor is the structure of a joint complex below the ankle joint, called the subtalar joint. The movement of this joint complex causes the arch of the foot to flatten and to heighten. Flattening of the arch of the foot is termed pronation and heightening of the arch is called supination. If there is excessive pronation of the foot during walking and standing, the plantar fascia is strained. Over time, this will cause a weakening of the ligament where it attaches into the heel bone, causing pain. When a person is at rest and off of their feet, the plantar fascia attempts to mend itself. Then, with the first few steps the fascia re-tears causing pain. Generally, after the first few steps the pain diminishes. This is why the heel pain tends to be worse the first few steps in the morning or after rest. Another factor that contributes to the flattening of the arch of the foot is tightness of the calf muscles. The calf muscle attaches into the foot by the achilles tendon into the back of the heel. When the calf muscle is tight it limits the movement of the ankle joint. When ankle joint motion is limited by the tightness of the calf muscle it forces the subtalar joint to pronate excessively. Excessive subtalar joint pronation can cause several different problems to occur in the foot. In this instance, it results in excessive tension of the plantar fascia. Tightness of the calf muscles can be a result of several different factors. Exercise, such as walking or jogging will cause the calf muscle to tighten. Inactivity or prolonged rest will also cause the calf muscle to tighten. Women who wear high heels and men who wear western style cowboy boots will, over time, develop tightness in the calf muscles.
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.
Diagnosis
To arrive at a diagnosis, the foot and ankle surgeon will obtain your medical history and examine your foot. Throughout this process the surgeon rules out all the possible causes for your heel pain other than plantar fasciitis. In addition, diagnostic imaging studies such as x-rays or other imaging modalities may be used to distinguish the different types of heel pain. Sometimes heel spurs are found in patients with plantar fasciitis, but these are rarely a source of pain. When they are present, the condition may be diagnosed as plantar fasciitis/heel spur syndrome.
Non Surgical Treatment
Recommended treatments, heel Spurs: cushioning for the heel is of little value. Your chiropodist/podiatrist may initially apply padding and strapping to alter the direction of stretch of the ligament. This is often successful at reducing the tenderness in the short term. Your chiropodist/podiatrist may suggest a course of deep heat therapy to stimulate the healing processes, allowing damage to respond and heal faster. In the long term, your chiropodist/podiatrist may prescribe special insoles (orthoses) to help the feet to function more effectively, thereby reducing strain on the ligaments and making any recurrence less likely. If pain from heel spurs continues, you may be referred to your GP who can prescribe an oral non-steroidal anti-inflammatory. Alternatively, localised hydrocortisone injection treatment may be given by your GP or an appropriate chiropodist/podiatrist. If pain persists, surgery may be considered. Heel Bursitis: in most cases, attention to the cause of any rubbing, and appropriate padding and strapping by your chiropodist/podiatrist will allow the inflammation to settle. If infection is present, your chiropodist/podiatrist will refer you to your GP for antibiotics. Heel Bumps: adjustments to footwear is often enough to make them comfortable. A leather heel counter and wearing boots may help. However, if pain persists, surgery may be necessary.
Surgical Treatment
It is rare to need an operation for heel pain. It would only be offered if all simpler treatments have failed and, in particular, you are a reasonable weight for your height and the stresses on your heel cannot be improved by modifying your activities or footwear. The aim of an operation is to release part of the plantar fascia from the heel bone and reduce the tension in it. Many surgeons would also explore and free the small nerves on the inner side of your heel as these are sometimes trapped by bands of tight tissue. This sort of surgery can be done through a cut about 3cm long on the inner side of your heel. Recently there has been a lot of interest in doing the operation by keyhole surgery, but this has not yet been proven to be effective and safe. Most people who have an operation are better afterwards, but it can take months to get the benefit of the operation and the wound can take a while to heal fully. Tingling or numbness on the side of the heel may occur after operation.
back of heel cushions
Prevention
A variety of steps can be taken to avoid heel pain and accompanying afflictions. Wear shoes that fit well-front, back, and sides-and have shock-absorbent soles, rigid shanks, and supportive heel counters. Wear the proper shoes for each activity. Do not wear shoes with excessive wear on heels or soles. Prepare properly before exercising. Warm up and do stretching exercises before and after running. Pace yourself when you participate in athletic activities. Don't underestimate your body's need for rest and good nutrition. If obese, lose weight.
Heel pain is often a symptom caused by one of two conditions: Plantar Fasciitis or Achilles Tendonitis. Most commonly, heel pain experienced at the bottom of the heel is caused by plantar fasciitis. Heel pain may become so severe for some that just putting weight on their feet first thing in the morning is excruciating. Walking or running may feel completely out of the question.
Causes
To understand the cause of the pain one must understand the anatomy of the foot and some basic mechanics in the function of the foot. A thick ligament, called the plantar fascia, is attached into the bottom of the heel and fans out into the ball of the foot, attaching into the base of the toes. The plantar fascia is made of dense, fibrous connective tissue that will stretch very little. It acts something like a shock absorber. As the foot impacts the ground with each step, it flattens out lengthening the foot. This action pulls on the plantar fascia, which stretches slightly. When the heel comes off the ground the tension on the ligament is released. Anything that causes the foot to flatten excessively will cause the plantar fascia to stretch greater that it is accustom to doing. One consequence of this is the development of small tears where the ligament attaches into the heel bone. When these small tears occur, a very small amount of bleeding occurs and the tension of the plantar fascia on the heel bone produces a spur on the bottom of the heel to form. Pain experienced in the bottom of the heel is not produced by the presence of the spur. The pain is due to excessive tension of the plantar fascia as it tears from its attachment into the heel bone. Heel spur formation is secondary to the excessive pull of the plantar fascia where it attaches to the heel bone. Many people have heel spurs at the attachment of the plantar fascia with out having any symptoms or pain. There are some less common causes of heel pain but they are relatively uncommon. There are several factors that cause the foot to flatten and excessively stretching the plantar fascia. The primary factor is the structure of a joint complex below the ankle joint, called the subtalar joint. The movement of this joint complex causes the arch of the foot to flatten and to heighten. Flattening of the arch of the foot is termed pronation and heightening of the arch is called supination. If there is excessive pronation of the foot during walking and standing, the plantar fascia is strained. Over time, this will cause a weakening of the ligament where it attaches into the heel bone, causing pain. When a person is at rest and off of their feet, the plantar fascia attempts to mend itself. Then, with the first few steps the fascia re-tears causing pain. Generally, after the first few steps the pain diminishes. This is why the heel pain tends to be worse the first few steps in the morning or after rest. Another factor that contributes to the flattening of the arch of the foot is tightness of the calf muscles. The calf muscle attaches into the foot by the achilles tendon into the back of the heel. When the calf muscle is tight it limits the movement of the ankle joint. When ankle joint motion is limited by the tightness of the calf muscle it forces the subtalar joint to pronate excessively. Excessive subtalar joint pronation can cause several different problems to occur in the foot. In this instance, it results in excessive tension of the plantar fascia. Tightness of the calf muscles can be a result of several different factors. Exercise, such as walking or jogging will cause the calf muscle to tighten. Inactivity or prolonged rest will also cause the calf muscle to tighten. Women who wear high heels and men who wear western style cowboy boots will, over time, develop tightness in the calf muscles.
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.
Diagnosis
To arrive at a diagnosis, the foot and ankle surgeon will obtain your medical history and examine your foot. Throughout this process the surgeon rules out all the possible causes for your heel pain other than plantar fasciitis. In addition, diagnostic imaging studies such as x-rays or other imaging modalities may be used to distinguish the different types of heel pain. Sometimes heel spurs are found in patients with plantar fasciitis, but these are rarely a source of pain. When they are present, the condition may be diagnosed as plantar fasciitis/heel spur syndrome.
Non Surgical Treatment
Recommended treatments, heel Spurs: cushioning for the heel is of little value. Your chiropodist/podiatrist may initially apply padding and strapping to alter the direction of stretch of the ligament. This is often successful at reducing the tenderness in the short term. Your chiropodist/podiatrist may suggest a course of deep heat therapy to stimulate the healing processes, allowing damage to respond and heal faster. In the long term, your chiropodist/podiatrist may prescribe special insoles (orthoses) to help the feet to function more effectively, thereby reducing strain on the ligaments and making any recurrence less likely. If pain from heel spurs continues, you may be referred to your GP who can prescribe an oral non-steroidal anti-inflammatory. Alternatively, localised hydrocortisone injection treatment may be given by your GP or an appropriate chiropodist/podiatrist. If pain persists, surgery may be considered. Heel Bursitis: in most cases, attention to the cause of any rubbing, and appropriate padding and strapping by your chiropodist/podiatrist will allow the inflammation to settle. If infection is present, your chiropodist/podiatrist will refer you to your GP for antibiotics. Heel Bumps: adjustments to footwear is often enough to make them comfortable. A leather heel counter and wearing boots may help. However, if pain persists, surgery may be necessary.
Surgical Treatment
It is rare to need an operation for heel pain. It would only be offered if all simpler treatments have failed and, in particular, you are a reasonable weight for your height and the stresses on your heel cannot be improved by modifying your activities or footwear. The aim of an operation is to release part of the plantar fascia from the heel bone and reduce the tension in it. Many surgeons would also explore and free the small nerves on the inner side of your heel as these are sometimes trapped by bands of tight tissue. This sort of surgery can be done through a cut about 3cm long on the inner side of your heel. Recently there has been a lot of interest in doing the operation by keyhole surgery, but this has not yet been proven to be effective and safe. Most people who have an operation are better afterwards, but it can take months to get the benefit of the operation and the wound can take a while to heal fully. Tingling or numbness on the side of the heel may occur after operation.
back of heel cushions
Prevention
A variety of steps can be taken to avoid heel pain and accompanying afflictions. Wear shoes that fit well-front, back, and sides-and have shock-absorbent soles, rigid shanks, and supportive heel counters. Wear the proper shoes for each activity. Do not wear shoes with excessive wear on heels or soles. Prepare properly before exercising. Warm up and do stretching exercises before and after running. Pace yourself when you participate in athletic activities. Don't underestimate your body's need for rest and good nutrition. If obese, lose weight.