Heel Pain Has Many Causes

In our pursuit of healthy bodies, pain can be an enemy. In some instances, however, it is of biological benefit. Pain that occurs right after an injury or early in an illness may play a protective role, often warning us about the damage we've suffered.

When we sprain an ankle, for example, the pain warns us that the ligament and soft tissues may be frayed and bruised, and that further activity may cause additional injury.

Pain, such as may occur in our heels, also alerts us to seek medical attention. This alert is of utmost importance because of the many afflictions that contribute to heel pain.

Heel Pain

Heel pain is generally the result of faulty biomechanics (walking gait abnormalities) that place too much stress on the heel bone and the soft tissues that attach to it. The stress may also result from injury, or a bruise incurred while walking, running, or jumping on hard surfaces; wearing poorly constructed footwear; or being overweight.

The heel bone is the largest of the 26 bones in the human foot, which also has 33 joints and a network of more than 100 tendons, muscles, and ligaments. Like all bones, it is subject to outside influences that can affect its integrity and its ability to keep us on our feet. Heel pain, sometimes disabling, can occur in the front, back, or bottom of the heel.

Heel Spurs

A common cause of heel pain is the heel spur, a bony growth on the underside of the heel bone. The spur, visible by X ray, appears as a protrusion that can extend forward as much as half an inch. When there is no indication of bone enlargement, the condition is sometimes referred to as "heel spur syndrome."

Heel spurs result from strain on the muscles and ligaments of the foot, by stretching of the long band of tissue that connects the heel and the ball of the foot, and by repeated tearing away of the lining or membrane that covers the heel bone. These conditions may result from biomechanical imbalance, running or jogging, improperly fitted or excessively worn shoes, or obesity.

Plantar Fasciitis

Plantar fasciitis (heel-spur syndrome) is a common problem among people who are active in sports, particularly runners. It starts as a dull intermittent pain in the heel which may progress to a sharp persistent pain. Classically, it is worse in the morning with the first few steps, after sitting, after standing or walking, and at the beginning of sporting activity.

The plantar fascia is a thick fibrous material on the bottom of the foot. It is attached to the heel bone (calcaneus), fans forward toward the toes, and acts like a bowstring to maintain the arch of the foot.

A problem may occur when part of this inflexible fascia is repeatedly placed under tension, as in running. Tension causes an overload that produces an inflammation usually at the point where the fascia is attached to the heel bone. The result is pain.

Plantar fascia injury may also occur at midsole or near the toes. Since it is difficult to rest the foot, the problem gradually becomes worse because the condition is aggravated with very step. In severe cases, the heel is visibly swollen. The problem may progress rapidly and treatment must be started as soon as possible.

The inflammatory reaction at the heel bone may produce spike-like projections of new bone called heel spurs. They sometimes show on x-rays. Theyd o not cause the initial pain, nor do they cause the initial problem; they are a result of the problem. But later, having to walk on spurs may cause sharp pain.

Contributing Factors

Flat (pronated) feet
High arched, rigid feet
Poor shoe support
Tow running, hill running
Soft terrain (i.e., running on sand)
Increasing age
Sudden weight increase
Sudden increase in activity level
Family tendency

Treatment

Improvement may take longer than expected, especially if the condition has existed for a long time. During recovery, loss of excess weight, good shoes, and sedentary activities all help the injury to heal. You should return to full activity gradually.

Rest. Use pain as your guide. If your foot is too painful, rest it.

Ice. Ice the sore area for 10 to 15 minutes several times a day to reduce the inflammation. Apply a plastic bag of crushed ice over a towel. You should also ice the sore area for 15 minutes after activity.

Medication. If your condition developed recently, anti-inflammatory/analgesic medication (in tablet form, such as Advil or Ibuprofen), coupled with heel pads (see below) may be all that is necessary to relieve pain and reduce inflammation. If no pain relief has occurred after two or three weeks, however, your doctor may inject either cortisone or local anesthetic directly into the tender area.

Physical Therapy. The initial objective of physical therapy (when needed) is to decrease the inflammation. Later, the small muscles of the foot can be strengthened to support the weakened plantar fascia.

Heel Pads/Heel Cups. A heel pad of felt, sponge, or a newer synthetic material can help to spread, equalize, and absorb the shock as your heel lands, thus easing the pressure on the plantar fascia. It may be necessary to cut ah ole in the heel pad so the painful area will not be irritated. Your doctor will tell you where you can get heel pads; they are available at some medical-supply and sporting-goods stores. For more severely rated heel pain, more aggressive use of bracing (TriLoK) or casting.

Z-CoiL® Shoes. Poorly fitting shoes can cause plantar fasciitis. The best type of shoe to wear is a good running shoe with excellent support. The shoe should be chosen that fits best. Experiment with your athletic shoes to find a pair that is comfortable and gives you fewer symptoms.

As a courtesy, we can bill your insurance company, but you are responsible for full payment at the time of purchase. See the attached form HERE for more detailed information.

Orthoses. Orthoses (sometimes misnamed “orthotics”) are shoe inserts that your doctor will prescribe if necessary. Sometimes over-the-counter Powersteps or custom-made orthoses need to be added.

Taping. Your doctor may tape your foot to maintain the arch; this will take some of the tension off the plantar fascia. Z-CoiLs have good arch supports.

Surgery. Surgery is rarely required for plantar fasciitis. It would be considered only if all forms of more conservative treatment fail and if the pain is still incapacitating after several months of treatment. When needed, surgery involves removal of the bone spur and release of the plantar fascia.

Other products available for purchase at both of our locations include the TriLoK and Powerstep product line, heel cups and pads, and BioFreeze pain relief products.

Sports

Plantar fasciitis can be aggravated by all weight-bearing sports. Any sport where the foot lands repeatedly, such as running or jogging, can aggravate the problem. The injury may be precipitated by a sudden weight increase, changes in activity profile, or return to activity suddenly after a long period of rest, as in a case. To maintain cardiovascular fitness, weight-bearing sports can be temporarily replaced by non-weight-bearing sports (i.e., swimming, cycling). Weight training can be used to maintain leg strength.

When recovering from plantar fasciitis, return to sports activities slowly. If you have a lot of pain either during the activity of the following morning, you are doing too much. Using heel pads of changing to different or new shoes may help the problem.

The following exercises are designed to strengthen the small muscles of the foot to help support the damaged area. If done regularly, they will help prevent re-injury. DO EACH PRESCRIBED EXERCISE TWO TIMES A DAY OR AS OFTEN AS YOUR DOCTOR RECOMMENDS.

Towel Curls. Place towel on the floor and curl it toward you, using only the toes of your injured foot. Resistance can be increased with a weight on the end of the towel. Relax, then repeat the towel curl.

Shin Curls. Run your injured foot slowly up and down the shin of your other leg as you try to grab the shin with your toes. A similar exercise can be done curling your toes around a tin can.

Stretches. At first, non-weight bearing stretching before rising out of bed is recommended – try to touch your toes. Stretch your Achilles tendon (which is behind your calf), while sitting on the ground with your feet extended in front of you. Try to touch your toes. Protect your back by doing one leg stretch at a time.

As your heel is improving, stand at arm’s length from a counter or table with your back knee locked and your front knee bent. Slowly lean toward the table, pressing forward until a moderate stretch is felt in the calf muscles of your straight leg. Hold 15 seconds. Keeping both heels on the floor, bend the knee of your straight leg until a moderate stretch is felt in your Achilles tendon. (Tendons attach muscles to bones; the Achilles tendon attaches the muscles of the calf to the heel bone.) Hold 15 seconds of more. You should feel a moderate pull in your muscles and tendon, but no pain. Change legs and stretch the other leg.

Excessive Pronation

Heel pain sometimes results from excessive pronation. Pronation is the normal flexible motion and flattening of the arch of the foot that allows it to adapt to ground surfaces and absorb shock in the normal walking pattern.

As you walk, the heel contacts the ground first; the weight shifts first to the outside of the foot, then moves toward the big toe. The arch rises, the foot generally rolls upward and outward, becoming rigid and stable in order to lift the body and move it forward. Excessive pronation—excessive inward motion—can create an abnormal amount of stretching and pulling on the ligaments and tendons attaching to the bottom back of the heel bone. Excessive pronation may also contribute to injury to the hip, knee, and lower back.

Disease & Heel Pain

Some general health conditions can also bring about heel pain.

Rheumatoid arthritis and other forms of arthritis, including gout, which usually manifests itself in the big toe joint, can cause heel discomfort in some cases.
Heel pain may also be the result of an inflamed bursa (bursitis), a small, irritated sack of fluid; a neuroma (a nerve growth); or other soft-tissue growth. Such heel pain may be associated with a heel spur, or may mimic the pain of a heel spur.
Haglund's deformity ("pump bump") is a bone enlargement at the back of the heel bone, in the area where the Achilles tendon attaches to the bone. This sometimes painful deformity generally is the result of bursitis caused by pressure against the shoe, and can be aggravated by the height or stitchng of a heel counter of a particular shoe.
Pain at the back of the heel is associated with inflammation of the achilles tendon as it runs behind the ankle and inserts on the back surface of the heel bone. The inflammation is called achilles tendonitis. It is common among people who run and walk a lot and have tight tendons. The condition occurs when the tendon is strained over time, causing the fibers to tear or stretch along its length, or at its insertion on to the heel bone. This leads to inflammation, pain, and the possible growth of a bone spur on the back of the heel bone. The inflammation is aggravated by the chronic irritation that sometimes accompanies an active lifestyle and certain activities that strain an already tight tendon.
Bone bruises are common heel injuries. A bone bruise or contusion is an inflammation of the tissues that cover the heel bone. A bone bruise is a sharply painful injury caused by the direct impact of a hard object or surface on the foot.
Stress fractures of the heel bone also can occur, but these are less frequent.

Children’s Heel Pain

Heel pain can also occur in children, most commonly between ages 8 and 13, as they become increasingly active in sports activity in and out of school. This physical activity, particularly jumping, inflames the growth centers of the heels; the more active the child, the more likely the condition will occur. When the bones mature, the problems disappear and are not likely to recur. If heel pain occurs in this age group, podiatric care is necessary to protect the growing bone and to provide pain relief. Other good news is that heel spurs do not often develop in children.

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.

Podiatric Medical Care

If pain and other symptoms of inflammation—redness, swelling, heat—persist, you should limit normal daily activities and contact a doctor of podiatric medicine.

The podiatric physician will examine the area and may perform diagnostic X rays to rule out problems of the bone.

Early treatment might involve oral or injectable anti-inflammatory medication, exercise and shoe recommendations, taping or strapping, or use of shoe inserts or orthotic devices. Taping or strapping supports the foot, placing stressed muscles and tendons in a physiologically restful state. Physical therapy may be used in conjunction with such treatments.

A functional orthotic device may be prescribed for correcting biomechanical imbalance, controlling excessive pronation, and supporting of the ligaments and tendons attaching to the heel bone. It will effectively treat the majority of heel and arch pain without the need for surgery.

Only a relatively few cases of heel pain require more advanced treatments or surgery. If surgery is necessary, it may involve the release of the plantar fascia, removal of a spur, removal of a bursa, or removal of a neuroma or other soft-tissue growth.