Expert Heel Pain Advice

Updated on December 14, 2016

Plantar Fasciitis

Heel pain can have many different causes, but the most common one is plantar fasciitis, which can be associated with heel spurs and policeman's heel. Plantar fasciitis is fundamentally an inflammation of the foot that is caused by the wear and tear of an area of tissue close to the heel arch.

Diagnosing plantar fasciitis is usually straightforward. This condition is characterized by sharp pain in the foot first thing in the morning; typically followed by a significant reduction in pain as you start to walk for a period of time; followed finally by a return of the pain later in the day. You may also observe increased pain after a period of physical activity.

However, if you find that you suffer more in the evening, or if you notice that the pain occurs more often when you are resting, and that it is sometimes accompanied by back pain, this is unlikely to be due to plantar fasciitis. These symptoms are more likely to be caused by pressure on your sciatic nerve, which can result in referred pain in your heel. Nerve irritation in your leg or back may be to blame if you are experiencing heel pain without back pain. The best advice is to see a clinician if you are suffering from any pain in order to be properly diagnosed and treated.

Consult Your Clinician

If you are experiencing unexplained pain in your heel, the best advice is to see your doctor or medical clinician for proper diagnosis and treatment.

Arthritic Conditions

Heel pain can also be caused by rheumatological diseases, and due to their similarity in symptoms the pain caused can often be mistaken for those of plantar fasciitis. Rheumatological diseases such as Psoriatic Arthritis, Reactive Arthritis, and Ankylosing Spondylisis, are often the most likely to cause heel pain through an inflammation in the heel. Again the best advice would be to visit a clinician if you or your family have a history of arthritic conditions so that the best form of heel pain treatment can be recommended.

Heel Fat Pad Atrophy

Another cause of heel pain may be when the cushioning fat pad on the heel is lost and leaves you with a bruised calcaneus or heel bone. How can you tell? Simple. Pinch the skin under your heel? Can you feel a very hard lump at the bottom of your heel? If so it is likely you have a heel fat pad problem! Want further confirmation? Try this. Walk along a hard floor, a fat pad condition is probable if the pain only occurs when you heel hits the ground. Plantar fasciitis is likely if the pain is when the heel is lifted off the ground.

Heel pain in children

It is not only adults that get heel pain; children can suffer too. This is often the result of participation in sports such as football and netball. The clearest indication of suffering can be seen as the child is getting out of a chair or a car after a short rest following a sport session.

Sever's is the name given to this condition and is a form of fatigue fracture of the growing bone at the back of the heel where the Achilles tendon attaches. The most simple advice concerning this cause of heel pain is to promote a period of time where sporting activities are abstained or reduced so as not to aggravate the problem. However alike to adults if this heel pain is occurring in the evening, consult a clinician.

What is Plantar Fasciitis?

Just to give you a little background, plantar comes from the word foot, fascia denotes the fibrous tissues that anchor the heel bone (calceneus) to the metatarsal bones situated at the base of your toes, and itis infers inflammation. Hence the name!

To understand plantar fasciitis further, an understanding of the mechanics of the condition is needed.

A good way to grasp the mechanics is through thinking of a wheelbarrow! Effort is applied at the handles when you lift the contents of a wheelbarrow and rotation occurs at the wheel (in this case the fulcrum). The load (resistance) is held up by the body of the wheelbarrow (our lever). As we apply more pressure and effort we are able to tip the contents of the wheelbarrow out on the ground.

As we lift the heel off the floor we apply effort at the back of the heel by the calf muscles via the Achilles tendon. Our toe joints (metatarsal phalangeal joints) become our wheel (fulcrum) allowing for rotation. The load (resistance) is our body weight moving onto the next foot. The plantar fascia and the muscles under the foot hold the foot firmly so it becomes the rigid body of the wheelbarrow (lever). As the fascia tightens due to the toes bending upwards the foot should become stiffer. This allows us to tip our body weight onto the next foot.

However, if the calf muscles are tight, we are forced to lift the heel too early, which means it’s difficult to move the weight onto the next foot, and it isn't ready to receive it.

This results in increased strain on the plantar fascia. When the calf muscle is weak this creates a delay in the heel lifting and means body weight travels too far forward before the foot has had chance to stiffen. If it is the case that the foot muscles are too weak this means that when the foot is lifted off the ground it becomes too flexible. As the load pushes down on the foot it flattens and lengthens it, again applying more pressure and increasing strain on the plantar fascia. Finally if the feet are highly arched and the plantar fascia is too stiff there will be no give present, which would give the foot the ability to flatten and spring back. With no ability to stretch out the foot will end up pulling on its attachments and as the weakest attachment is at the heel, the fascia attachment will gradually become over strained.

What are Heel Spurs?

Until recently heel spurs were seen to be the root cause of heel pain due to the limitations of tools available to diagnose heel ailments. As X rays only highlight boney pathology it is no surprise that any bone abnormality was attributed to the cause of heel pain. People with heel pain often showed a spike of bone growing out of the medial process of the heel bone, this being the main attachment point of the plantar fascia.

This boney spike therefore was thought to be the cause of heel pain for a considerable amount of time. However after more detailed research it was agreed that the heel spur instead moves as a flat extension when viewed from the bottom of the heel.

It took a few helping points to quash the theory that heel spurs were the cause of the heel pain. The first being that heel spurs were appearing frequently on X rays of people that had never expressed any heel pain. Also new technology was introduced which has allowed a greater understanding of soft tissues, and through MRIs and ultrasounds,fluid in the fascia and heel bone have been detected helping to dispel heel spurs myths.

So now we know that heel spurs don’t cause heel pain, but how do they come about? Heel spurs are thought to form in the following way. Bone is stimulated to grow under compression and the heel spur forms under the plantar muscles of the foot but above the plantar fascia.This means that it is in turn acting as a kind of boney sandwich filler between two slices of the support structures of the proximal arch of the foot. As the plantar fascia is under increased strain, the muscles have to contract hard to support the arch of the foot and the far edge of the plantar tubercle is squeezed meaning that this compression forms the bone plateau.

It may be helpful to consult a clinician if you are still unsure whether you are suffering from heel spurs or if you need treatment for your heel spurs.

What is Policeman's Heel?

Policeman’s heel is the name given to a protective sack of fluid that can form under the heel bone. It is often seen in people that suffer from poor fat pad on their heel and is far less common these days than conditions such as plantar fasciitis. It had not always been this way though as in the days when X- rays were the only way of diagnosing heel pain, if a spur was not found, the diagnosis was concluded as policeman’s heel as there were no ultrasounds or MRI’s to assess the soft tissue.

Understanding Heel Pain

Most heel pain problems are due too much strain when your heel leaves the floor due to structures on the sole of the foot; hence the pain often felt when you rise on to your toes. The most common structure to be injured is that of the plantar fascia.

The plantar fascia is made of tough fibrous tissue that tightens when your toes are bent upwards. It helps hold the heel and the forefoot together when you stand, and shortens the distance between the heel and the forefoot when you rise up on to your toes. This in turn effectively raises the arch of your foot.

When we stand or walk our foot is made stable through layers of muscle under the plantar fascia that work to pull the heel and forefoot together. In addition to this there are strong muscles that are situated deep in the back of your leg that pull firmly on your toes to keep the forefoot stable when your heel is lifted off the ground. All these muscles help to protect the plantar fascia and keep the heel and forefoot from stretching away from each other.

Under the skin and below the plantar fascia is the plantar fat pad of the heel. This is an impressive structure that stops the heel bone (calcaneus) getting bruised as we walk. This is so effective that bruising of the heel is very rare, unless the fat pad wastes away. This can happen in diseases of poor circulation, but in rare cases can happen without an obvious cause.

Finally we have the Achilles tendon attaching to the back of the heel. The Achilles is attached to two powerful muscles, called the gastrocnemius and soleus. These muscles stop the body falling forward as our body weight passes over the foot, then lifts the heel off the ground. Problems with the calf muscles and Achilles tendon are common, and will directly strains through the foot. Achilles pain is  felt at the back of the heel rather than underneath it. However, like plantar heel pain, the pain is often worse first thing in the morning or after exercise. If your calf muscles are tight or weak (or both) then increased strain will be put on the plantar fascia and muscles.

Heel Pain in Sports

Although most cases of heel pain are not associated with sports, there are still a considerable number of cases each year. The worst-offending sport is running. The most common type of heel pain associated with sports is Sever’s, which affects children usually from 9 to 13 years of age. There are three common types of heel pain associated with adults playing sports. These are plantar fasciitis, Achilles tendinopathies, and Haglund’s or pump bumps. These conditions are most common in runners, but also those who participate in sports such as football, cricket, rugby, and hockey.

Sever’s in Sports

In childhood, our bones are made of a cartilage mold of the bone, which as we grow over time slowly develops into a full bone. Most bones have at least two growth of bone centres, one is situated by the joint and the other one makes the main body of the bone. In the growing heel bone the posterior part has a separate growth area where the Achilles tendon attaches.

When playing lots of sports, especially football, rugby, and hockey, the two areas of bone can be pulled apart and this can generate a lot of pain. Recent evidence has also suggested that the appearance of this condition on MRI scans appears to indicate that Sever’s is a type of stress fracture.

Plantar Fasciitis in Sports

Although plantar fasciitis can occur in any sport, again running is the most common sport it occurs with. Injury to the plantar fascia can occur at any age, but is more common in runners over 35 years. As we age our soft tissues become less elastic, and consequently become easier to strain. Pain is often noticeable after you rise from sitting or after you get out of the car after driving home after a run. Before long it will start hurting first thing in the morning too.

However, many people feel the pain suddenly and sharply, often during sport in situations such as reaching for a tackle. Working out how the condition occurred may be slightly difficult for the sufferer but it is very helpful and can help reveal the type of damage that has occurred, and that can help with finding the right kind of treatment for plantar fasciitis.

Achilles Tendinitis in Sports

Achilles tendonitis is the most common heel pain for runners also known as Achilles tendinopathy, as it is a mixture of degenerative and inflammatory changes in the tendon. Pain is felt at the posterior part of the heel, which can radiate a few cm up towards the calf. Gentle squeezing of the Achilles or pressure on the posterior part of the heel bone can help to locate the pain to the Achilles and its structures.

Although all types of sporting foot shapes can develop Achilles problems, those runners who strike the ground on their forefoot, especially if they are new to running, or if they have recently increased their pace and distance have a greater risk.

Typically Achilles tendinopathy is divided into two main types of injury. These are insertional and non-insertional.

Insertional Injuries

Insertional injuries are generally more common in high arch feet, where it can be harder to lift the heel off the ground. This causes increased strain in the attachment and increased compression on the Achilles where it lays over the bone.

Non-Insertional Injuries

Non-insertional injuries are the most common type of Achilles injury. The tendon itself or the sleeve that covers it can be injured. Sometimes the inside of the tendon is more painful, sometimes the outside. Where the injury lies gives a clue as to where the strain is running into the tendon. If you have recently got new shoes and then shortly developed Achilles pain after, especially if it is right on the posterior edge of the tendon, then check out your shoes.

Haglund’s in Sports

Haglund’s deformity is also known as a “pump bump”. This deformity is the enlargement of the posterior part of the heel bone and soreness of the skin over the boney lump. Often there is a painful blister. The boney bump usually grows during teenage years, when the growing heel bone can be rubbed by footwear, usually sports shoes, causing increased blood flow to the bone. This leads to excessive bone growth.

Haglund’s can be quite painful, particular for those who wear tight football boots. The heel counter of the boot continually irritates the heel. Sometimes softening the back of the heel counter of the boot or trainer with a hammer can solve the problem. However, large Haglund’s may require surgical excision, so it is always worth checking with your clinician for further heel pain advice.

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