Heel Pain explained

Besides the formation of a calcaneal spur, pain in the heel area is a typical symptom of Plantar Fasciitis. Heel pain is one of the most common types of foot pain in adults and very often becoming appearent after increased daily activities such as work, exercise, walking long distances, walking up steps or stairs etc. A person may have had a spur or plantar fascia problems for a long time, but only until they increase their activities or gain weight the condition will result in pain or discomfort. Pain may occur at the bottom of the heel, but also at the back of the heel, a condition called Achilles Tendonitis. Other heel conditions include Bursitis and in children Severe’s Disease.

First let’s look at the anatomy of the heel. Two structures at the underside (the sole) of the foot are relevant in particular to heel pain: the plantar fascia or plantar aponeurosis in the sole of the foot and the flexor muscle (the Flexor digiti minimi brevis), together they form the arch of the foot. During walking and running the foot absorbs the weight of the body when the foot lands. The foot and ankle have a locking mechanism which raises the arch preparing the foot for the propulsive phase of gait. The plantar fascia stabilises the arch and provides stability of the 1st MP joint and medial arch through the windlass mechanism. This mechanism brings about plantar flexion of metatarsals, which elevates and stabilises the longitudinal arch, inverts the calcaneus and externally rotates the tibia (bones in the lower leg). The plantar fascia supports the arch of the foot by acting as a tie-rod, where it becomes tensed when weight is placed on the foot. The plantar fascia continuously elongates during the contact phase of gait.

What causes heel pain?

Heel pain is caused by irritation and inflammation of the plantar tissue and often leads to limited walking and standing. There are different causes for heel pain:

1) Fractures of the calcaneus: a fracture of the calcaneus (heel bone) and usually only occurs in long distance runners and can lead to chronic heel pain. 2) Achilles Tendon inflammation (or Achilles Tendonitis): inflammation of the Achilles tendon leading to pain at the back of heel.

However the most common cause of heel pain is inflammation of the connective tissue in the plantar aponeurosis due to excessive stress of the tendon. Many patients suffer from excessive pronation of the subtalar joint, causing poor foot function. This means that every step the arch lowers excessively and the ankle joint protudes inward. In turn this puts tension on the plantar fascia and continously pulling away from the calcaneus, which leads to micro-tearing of the ligament, irritation and ultimately inflammation, whereby walking is severely hampered. Effective treatment of heel pain can be achieved by restoring incorrect gait and foot function, by strengthening muscles and stretches tendons and ligaments. Foot orthotics are also used to correct gait and provide long-term heel pain relief. Other treatment options are rest, ice therapy, cortisone injections and as a last resort surgery. Surgery involves release of the plantar fascia by dissecting part of the fascia. Heel pain surgery is an absolute last resort and should be reserved for patients who have made every effort to fully participate in conservative treatments, but continue to have heel pain. In 99% of cases surgery is not necessary and conservative treatment should provide lasting pain relief for the patient.

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