In adults, plantar heel pain is responsible for approximately 11-15% of all foot issues needing professional attention.
What is heel pain?
Heel pain is an umbrella term used to describe pain or discomfort in the heel of the foot. The pain can be characterised as mild or severe and can impact one foot or both. Common characteristics include pain during the first few steps of the day and when performing weight-bearing activities, especially following periods of rest.
Posterior heel pain refers to pain at the back of your heel caused by conditions such as Haglund’s deformity, Achilles tendinopathy and sever’s disease. Conversely, plantar heel pain refers to pain at the bottom of your heel secondary to conditions such as plantar fasciopathy, tibial nerve entrapment or heel pad atrophy.
Heel pain impairs mental, physical and foot function, decreases mobility, and impacts your ability to work, leading to negative impacts on health-related quality of life.
Why do I wake up with Heel Pain in the morning?
Post-Static Dyskinesia, also known as after-rest pain is commonly associated with plantar fasciitis and accounts for that intense heel pain you might experience during your first few steps of the day. When sleeping, our feet are often pointed downward or ‘plantar-flexed’, causing the plantar fascia to shorten and tighten. Throughout periods of rest, your body attempts to heal itself from all the stresses it has undergone throughout the day. However, the first step of the day causes a sudden stretch to the plantar fascia upon weight bearing, forcefully pulling on the heel and causing intense sharp pain.
Types of heel pain
In adults, plantar fasciitis is the most common cause of heel pain, impacting both older sedentary and young active individuals. The plantar fascia (a thick band of tissue that starts at your heels and fans out to your toes) is responsible for providing shock absorption and arch support. Damage or inflammation to the plantar fascia, most commonly from recurrent stress causing micro-tears in the structure, results in localised sharp heel pain. Patients often complain that the first few steps of the day and activity after prolonged sitting causes immense pain.
The foot’s inability to adequately shock absorb or evert in a pes cavus (high-arched) foot type causes increased strain on the heel. Conversely, a pes planus (low-arched) foot type can place excessive strain at the plantar fascial origin site. Other risk factors include restricted dorsiflexion, tight calves, heel pad atrophy, obesity and occupations associated with prolonged weight bearing.
A heel spur is an atypical bony growth from the underside of the calcaneus (the heel bone). It is usually caused by prolonged stress on the muscles of the foot and the plantar fascia and is more commonly found in active joggers, runners and patients with an increased body mass. Heel spurs are typically asymptomatic. However, they can irritate the plantar fascia leading to moderate to high dull, throbbing or sharp heel pain, especially when running, jogging or walking. Some may even feel a small bony protrusion at the back or bottom of the heel, tingling/ numbness or burning.
Risk factors include poor footwear, increased age, active jumpers, runners and joggers as well as abnormalities in gait placing increased stress on the calcaneus and connecting tissues.
Sever’s disease, also known as calcaneal apophysitis is the most common cause of heel pain in children between 8-15. It is characterised by painful inflammation of the growth plate at the back of the heel secondary to repetitive pressure and stress in children that participate in high-impact sports or undergo a rapid growth spurt. Although this condition can be unilateral, more than 50% of cases present bilaterally. Additionally, males are affected more commonly than females. As a child grows, the muscle-tendon unit does not grow as quickly as bone. As a result, it is unable to stretch adequately to maintain its flexibility, causing swelling, soreness and greater tension through the unossified apophysis. Common symptoms of this condition include limping, swelling, tenderness or pain at the heel especially during or after activity.
Tight calf muscles lead to excessive strain through the Achilles tendon and increase the pull on the growth plate. Participation in high-impact sports involving running and jumping such as gymnastics, soccer, cross-country, ballet and tennis also increases the risk of developing this condition. Other risk factors include poor footwear, a pes planus foot posture and obesity.
Despite recurrence being common, this condition is self-limiting and is resolved at the closure of the heel growth plate, typically around 15-17 years of age once the child achieves skeletal maturity.
Diagnosing Heel Pain
As mentioned above, there are various causes for the development of heel pain. Therefore, a diagnosis is made based on a combination of the patient’s medical and pain history and clinical examination. If necessary, further investigation such as imaging can be a useful tool to aid diagnosis.
During your consultation, your podiatrist will ask you about your medical history including any medical conditions, medications, recent and past injuries or surgeries. Questions in relation to your pain including the site, onset, character, timing, severity and aggravating/ relieving and associated factors will assist in determining the cause of your pain. Your podiatrist will also assess your footwear, joint range of motion, muscle strength and gait.
Palpation is important when diagnosing heel pain. In plantar fasciopathy, pain is typically elicited when dorsiflexing the hallux and palpating the medial calcaneal tuberosity and the medial band of the plantar fascia. The squeeze test also helps to assess for stress fractures or sever’s disease and is conducted by applying mediolateral compression of the inferior one-third posterior calcaneus, resulting in immediate discomfort for the child as pressure is applied to the growth plate.
Treating Heel Pain
After determining the underlying cause of your pain, a goal-orientated management plan is developed through evidence-based practice, clinical reasoning and shared decision-making.
Depending on the cause, treatment options include:
- Rest from aggravating activities
- Oral or topical non-steroidal anti-inflammatory medication (as directed by your health practitioner) to decrease pain and inflammation
- Heat or Ice depending on the stage of your condition
- Stretching and strengthening exercises
- Taping to stabilise the foot and ankle while decreasing increased stress on the plantar fascia
- Heel lifts to take pressure away from the heel
- Appropriate footwear to help support, protect and stabilise the foot and ankle while aiding shock absorption
- Orthotics to offload excessive stress placed on the plantar fascia and address potential causative factors such as poor foot posture or help control hypermobility
- Shockwave therapy turns chronic cases acute by stimulating the body’s immune cells to trigger its healing process and decrease healing times
- Surgical intervention when all conservative options have been exhausted