Have you ever experienced pain beneath your heel that stopped you from doing the things you enjoy – or that even made walking or resting uncomfortably?
Heel pain is a very common presentation at our clinic – and many factors can be involved.
There are at least 7 different causes of heel pain:
Plantar fasciitis is the most common cause of heel pain (I will discuss this in detail in this blog).
Heel spur is an abnormal bony outgrowth caused by long-term stress on the plantar fascia and foot muscles. Depending on its position, the spur may or may not be painful.
Heel fat pad atrophy occurs when the tissues of the heel (which usually consist of closely packed fat tissue and thick stretchy muscle fibres that provide cushioning and shock absorption) become reduced and damaged over time due to repetitive microtrauma and/or age.
Calcaneal stress fractures can occur with overuse and repetitive forces caused by a marked increase in intensity/duration of physical activity such as running.
Impingement of the nerve that innervates the muscles and skin of the plantar heel. You might experience pins and needles around the heel.
Chronic lower back pain can result in referred pain and numbness of the heel.
Systemic inflammatory conditions such as rheumatoid arthritis or seronegative spondyloarthropathies can cause inflammation of – and pain in – the heel.
So as you can see, heel pain can have a number of different causes. Make sure you check with your podiatrist to have your heel pain diagnosed and treated correctly.
Now I’ll talk about the most common heel pain: plantar fasciitis (sometimes also known as plantar fasciopathy).
What is plantar fasciitis?
Plantar fasciitis is most commonly diagnosed when a person experiences soreness or tenderness beneath the central part of the heel pad and sometimes the arch. Although the term ‘fasciitis’ means an inflammation of the fascia, there has been a shift away from using this term, as research has indicated that plantar fasciitis is not an inflammatory condition at all. Instead, it’s more of a chronic, degenerative condition of the plantar fascia and so the term plantar fasciopathy has been adopted, which simply means ‘pathology of the plantar fascia’.
However, I will continue to refer to this type of heel pain as ‘plantar fasciitis’, as it’s the most commonly used term.
Anatomy of the plantar fascia
The plantar fascia is a thick band of fibrous connective tissue, similar in appearance to tendons and ligaments. It originates from the medial tubercle of the calcaneus (the central part of the heel bone) and spans the arch, attaching into 3 different locations at the forefoot. This results in 3 distinct plantar fascial bands: medial, central, and lateral. The central band is the thickest and strongest, and is the usual plantar fascial band involved in plantar fasciitis; the medial and lateral bands are seldom involved.
Due to its anatomical position, the plantar fascia is involved in raising and stabilising the arch and aiding in shock absorption during the gait cycle. However, if it is exposed to abnormal levels of stress and has an inherent structural deficiency that is incapable of tolerating normal levels of stress, this can result in microdamage to the plantar fascia and, subsequently, degenerative changes.
Risk factors involved in the development of plantar fasciitis
Tight Achilles tendon, reduced ankle joint range of motion, and pronated foot type (flat feet) can increase stress and decrease the function of the plantar fascia during gait.
The highly arched foot type has poor shock absorption during the gait cycle, which results in increased plantar fascial load and strain.
Age: plantar fasciitis affects approximately 10% of the general adult population and is also common in the younger active population.
High body mass index or sudden weight gain.
Sudden increase in activity level.
Prolonged standing/walking.
Work-related weight-bearing activities.
Inappropriate footwear.
Presentation of pain
The pain of plantar fasciitis is often described as a sharp/dull aching/throbbing pain that is worse with the first few steps after getting out of bed or after rest. The pain can subside with walking or other physical activity but the intensity can increase throughout the day as activity increases.
Clinical examination:
Pain on palpation of the central part of the heel pad (the origin of the plantar fascia) and along the plantar fascia. Pain can sometimes also be reproduced when standing on tiptoe.
Tight plantar fascia.
Management of plantar fasciitis:
Non-steroidal anti-inflammatory medications taken orally or applied locally to provide short-term pain relief.
Physical therapy management – such as stretching and strengthening of calf muscles, intrinsic foot muscles and plantar fascia – to improve function and reduce pain.
Activity modification to reduce tissue stress.
Foot mobilisation therapy to improve joint mobility.
Deep friction massage of the plantar fascia to reduce pain.
Night splint to prevent plantar fascial contracture.
Orthotic therapy to help reduce the plantar fascial load and Achilles tendon forces in gait for improved foot function and reduced pain.
Shoes with good cushioning, support, shock absorption and gradient drop of height from the heel to the toes, or rocker-bottom soles, to help offload the plantar fascia.
Photobiomodulation therapy (light laser therapy) to reduce pain by stimulating tissue repair.
At Saltfleet Clinic, we offer all of these conservative management options for plantar fasciitis. Depending on your individual symptoms and requirements, we may recommend some or a selection of these options, while working with you to achieve your treatment goals.
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