Heel Pain

Heel pain is one of the most common problems encountered in orthopaedics, a medical speciality which deals with the abnormalities of the muscles and bones. It may lead to a significant limp and discomfort to the person due to problems in bearing weight. There are several causes that may lead to heel pain and proper clinical evaluation is important for optimal treatment. In most people, nonsurgical or conservative care has proven to be successful. Heel pain is often caused due to plantar fasciitis (inflammation or swelling of a thick ligament which connects the heel to the base of the toes), which is a reason why people often consult a doctor. In some people, plantar fasciitis may be associated with a bony outgrowth known as a calcaneal spur. In a study conducted in South India, it was found that 59% of the population had heel pain due to calcaneal spurs, with females being affected more than males.

What Is Heel Pain?

Pain in the heels is usually felt in the underside or back of the foot. Heel pain may not be a very serious condition, but it may cause discomfort in day-to-day activities, like while walking and exercising.

The symptoms of heel pain include:

• Stabbing pain at the base of the heel. Pain is usually worsened on walking the initial few steps after waking up or after rising from sitting position. Pain is aggravated after exercise.
• Shooting pain in the foot along with tingling or numbness or a burning sensation is a typical feature of tarsal tunnel syndrome.
• A pain felt in the centre of the heel is a typical symptom of heel bursitis.
• In Achilles tendinitis, the pain begins as a mild ache at the back of the heel after any sports activity. The severity of pain increases with prolonged sprinting, running or climbing.
• In Achilles tendon rupture, the person will have pain and swelling near the heel with a feeling of being kicked in the calf. There is an inability to push the foot downwards or stand on the toes of the affected leg. At the time of injury, a popping or snapping sound is heard.

There are several causes that can lead to heel pain. These include:

• Plantar fasciitis
  Plantar fasciitis is the most common cause of heel pain. It is said that 1 in every 10 people over 50 years of age complain of heel pain. This occurs when the fascia or the elastic band, which connects the heel bone to the base of the toes gets damaged. The most common is the faulty structure of the foot. People with flat feet or high arched feet are more prone to developing plantar fasciitis. Other conditions that may lead to plantar fasciitis include prolonged standing, excessive running and walking or a sedentary lifestyle. Even a change in body weight, road surface, improper shoe support or sudden stretching of the sole can lead to plantar fasciitis.
• Achilles tendon rupture
  The Achilles tendon is the strongest tendon of the body. It joins the muscles of the calves to the heel bone at the back. If the tendon is overstretched, it may tear partially or completely. Such injuries are common in people engaging in recreational sports, but it can happen to anybody. The rupture is more in the lower end of the tendon. This area is more prone to injury as the blood supply is poor and takes a longer time to heal. (Read more - Tendon injury treatment)
• Achilles tendinitis
  Repetitive or sudden intense strain on the Achilles tendon can lead to tendinitis (swelling or inflammation of a tendon). This is particularly seen in people who have recently increased the intensity of their activity. The structure of the tendon becomes weak as age advances making it more prone to injury. A naturally flat-footed person can put more strain on the tendon. Obesity and tight calf muscles add to the strain. Even running in worn-out shoes or cold weather or hilly areas increase the risk of Achilles injury. People taking certain antibiotics or those suffering from high blood pressure or psoriasis are also prone to Achilles tendinitis.
• Calcaneal spur
  If plantar fasciitis pain lasts for longer periods of time, there may be calcium deposition within the fascia band that connects the heel bone or calcaneus. This outgrowth is known as a calcaneal spur, which may vary in size. Heel spurs are often painless, though sometimes they may cause heel pain. They are often associated with plantar fasciitis. They are caused due to repeated stretching of the plantar fascia and tearing of the membrane covering the heel bone. Spurs are commonly found in athletes who indulge in running and jumping sports.
• Bursitis and heel bumps
  A bursa is a fluid-filled sac near a bone or a joint, which helps in smooth movements. The inflammation of the bursa underneath the heel bone is called subcalcaneal bursitis. In this condition, the pain is felt more in the centre of the heel and increases during the day. This condition is caused by a direct injury to the heel after landing from a height. Heel bumps are usually seen at the back of the heel caused by excessive rubbing of shoes in the heel area or by thickened tissues from a tight Achilles tendon. Sometimes prolonged inflammation of the heel pad reduces the thickness of the pad, giving rise to dull heel pain that worsens during the day.
• Stress fractures
  Stress fractures can be a result of repetitive force, from overuse or a sudden increase in the intensity of activity on weight-bearing bones. They may also occur in a normal bone that is weakened due to osteoporosis. Sports such as gymnastics, track and field, basketball and tennis are associated with higher risks of stress fractures. It can also occur in people with a sedentary lifestyle who suddenly begin active regimen and increase the duration or intensity of their workouts. People with eating disorders and a deficiency of vitamin D and calcium are also prone to developing stress fractures.
• Tarsal tunnel syndrome
  Tarsal tunnel syndrome is caused when the nerve of the leg gets trapped and compressed at the site where it enters the ankle. The person complains of burning and tingling sensation below the heel in the arches of the feet along with an intermittent loss of sensation in the base of the foot. People with flat feet experience immense strain on the foot, which can compress the nerve. Ankle swelling, arthritis, diabetes may also result in nerve compression. Abnormal swellings like ganglion cysts, bone spurs may also compress the nerve.
• Other conditions that cause heel pain include:
  • Bone tumours.
  • Osteomyelitis (infections of bone).
  • Neuropathies.
  • Arthritis.
  • Sarcoidosis (an abnormal collection of the cells of the lymphatic system leading to the formation of red bumps or patches on the skin, especially on the shins).
  • Paget’s disease of bone (a disorder of the bones affecting the skeletal structure).

Risk Factors

There are many factors that can increase the risk of heel pain. These include:

• Gender
  Certain conditions like Achilles tendinitis, tendon rupture are more common in men than women.
• Age
  The incidence of heel pain increase with age. The average age of people affected with plantar fasciitis is around 45 years.
• Weight
  Overweight and obese people put a lot of strain on the heel which may aggravate plantar fasciitis, heel spurs, tarsal tunnel syndrome among others.
• Foot mechanics
  People who are flat-footed, have high arches or simply those who have a wrong style of walking, the way the weight is distributed in the foot while standing or doing an activity gets affected. This adds stress to the fascia and the heel and leads to pain.
• Certain types of sports or exercises
  Certain activities like long-distance running, ballet dancing, jumping, and aerobics increase the stress on the feet, which can contribute to early onset of plantar fasciitis and heel pain. Even a change in the surface, for e.g., from grass to hard surface can damage the plantar fascia.
• Medications
  Steroids are sometimes used to treat ankle pain and inflammation. However, long-term usage may weaken the tendons and is often associated with Achilles tendon ruptures. Certain groups of antibiotics are also found to weaken the Achilles tendon.

Here are some tips for preventing heel pain:

• Heel pain can be prevented by daily stretching of the feet, calves and the Achilles tendon every morning, before and after exercising.
• Perform specific exercises to strengthen the calf muscles to handle the stress encountered during strenuous workouts.
• Begin with low impact training, and then gradually increase the level of activity depending on your endurance.
• Wear the right kind of shoes that fit and support the feet.
• Wear shoes particularly designed for the type of physical activity that you opt for.
• Pacing oneself is important in every activity.
• Maintain a healthy diet.
• Maintain proper weight.
• Take adequate rest when your muscles are tired.

A diagnosis is established based on the following:

• Physical examination
  A complete physical examination of the foot is carried out by an orthopaedic doctor. The doctor will inspect for tenderness, swelling, arthritis, a gap in the tendon, and nerve compression to arrive at a diagnosis. The feet will also be evaluated for flexibility, alignment, arches, the range of motion and reflexes of the ankle and feet.
• Complete exam
  A complete medical history is obtained to rule out other systemic conditions that could increase the risk of heel pain.
• X-ray
  Though X-rays cannot visualize soft tissues and tendons, they are useful to look for spurs, bony outgrowths, calcifications, and ganglion cysts (fluid-filled sacs formed on top of a tendon).
• Ultrasound
  Doctors will advise an ultrasound to look for tendons. Color Doppler ultrasound can also be advised to visualize blood flow around the tendon.
• MRI
  MRIs involve a very detailed imaging of the soft tissues and tendons which will help in establishing an accurate diagnosis.
• Nerve conduction studies
  Nerve conduction studies are often advised to rule out nerve compressions and tarsal tunnel syndromes.

Heel pain can be effectively managed by self-care measures. In people, where the signs and symptoms are severe, the doctor will suggest different options. Treatment is usually advised depending on the age, severity and activity level of the person.

• Medications
  Painkillers are usually prescribed to relieve the pain and inflammation. If over the counter medications do not help, stronger analgesics are prescribed.
• Physiotherapy
  Physiotherapy or physical therapy is always advised along with other treatment options. A therapist may suggest the following:
  • Exercises to stretch and strengthen the Achilles tendon and its supporting structures
  • Orthotic devices like shoe inserts, braces, splints, wedges that elevate the heel help to release the strain and provide a cushioning effect to the heel.
• Surgery
  If conservative approaches fail to provide relief or if the tendon is completely torn, a surgery is advised along with post-operative rehabilitation.

Lifestyle management

In addition to the medications and physiotherapy advised by the doctor, there are many lifestyle modifications that can help you in managing heel pain more effectively. These include:

• Rest
  Avoid exercise for a few days or stick to activities that do not strain the Achilles tendon or the plantar fascia. In people with severe pain, walking with a crutch is recommended.
• Ice
  To reduce the swelling and pain, apply ice on the area for 15 minutes after experiencing pain or after any activity. Wait for 40 minutes before icing again.
• Compression
  There are elastic bandages that can reduce inflammation and restricting movement of the tendon.
• Elevation
  Raise the feet above the level of the heart by placing pillows underneath them to reduce the swelling. Sleep with the feet elevated.
• Avoid ankle movement
  Avoid any movement of the ankle for the first few weeks, by securing it in a cast or a heel wedge with the foot in downward position.
• Wear the right shoes
  Wearing supportive shoes to minimize heel pain is recommended.
• Wear a brace
  People with a flat foot and those with severe nerve damage may need a brace to release the pressure on the foot.

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Prognosis

The outcome of heel pain depends on the person’s age and gender as well as the intensity, severity and mechanics of the foot. Plantar fasciitis in people with flat feet may have a poorer prognosis than those with normal arches. Nonsurgical treatment may be enough for some patients, whereas those with a full rupture of the Achilles tendon may require surgery with extensive physiotherapy.

Complications

Heel pain may lead to the following complications:

• Loss of balance leading to falls and injuries.
• Loss of sensation.
• Plantar fasciitis.
• Heel spurs.
• Chronic heel pain.
• Knee and back problems.