Heel Pain

There are 25+ conditions that can cause heel pain, the most common of which is ‘Plantar Fasciopathy’ or commonly referred to as ‘heel spurs’ or ‘plantar fasciitis’.


There is a common misconception that heel spurs are the cause of pain, but in fact, many people live day to day with spurs and have no symptoms relating to them. Generally, both the pain and the growth of the spur are related to irritation of the plantar fascia.


For most patients, plantar fasciopathy is caused by gait abnormalities that lead to the lengthening of the plantar fascia. Unlike an elastic tendon, the plantar fascia can be likened to a rope like structure and when lengthened rather than stretch, it tears. When lengthened, tensile is stress is placed along the fascial band or insertion site causing ‘microtrauma or micro tears’ to the area.

Clinically diagnosing

Palpation

  • Palpating the medial calcaneal tuberosity where the plantar fascia originates from, as well as along the medial plantar fascial band – The pain may be exacerbated when actively palpating while dorsiflexing the hallux.

Pain Presentation

  • Dull ache, sharp or burning may be described
  • Pain is generally most prominent in the first few steps of a morning, before easing throughout the day and returning at a similar intensity towards the end of the day.

Other Diagnostic tools may include imaging

Ultrasound

  • >4mm fascial thickening will normally have symptomatic involvement.
    Weight bearing X-rays – Not usually required (Can help to decrease unnecessary imaging)
  • To assess joint integrity, spacing and angles that may result in lengthening of the plantar fascia.

Differential Diagnosis

  • Tarsal Tunnel Syndrome
  • Baxter’s Nerve Entrapment
  • Plantar Fascial Rupture – Constant pain in region, nil resolution with persistent treatment
  • Fat Pad Syndrome

A key differential to consider being Tarsal Tunnel Syndrome (TTS) – Both conditions present medially, with TTS presenting slightly higher up the ankle and pain may radiate along the tibial nerve. Pain in TTS is usually worsened with walking, whereas plantar fasciopathy will ease after the first few steps.
When suspecting plantar fasciopathy, it is recommended rather than sending for cortisone injections patients should have the causative factor addressed first with either a podiatrist or alternatively a physiotherapist. Cortisone injections – recurrence rates can be high when the causative factors are not addressed and there are also associated risks to a plantar fascial rupture.

The most common causative risk factors are –

  • Compensatory pronation or supination – due to:
    • Hypermobility or rigidity of joints within the foot
    • Tight or weakened muscle groups – particularly acquired ankle equinus
  • Pes planus (low-arched) or pes cavus (high-arched) foot types
  • Poor footwear choices
  • Increased activity or BMI within a short space of time

Treatment plans revolve around acute pain management and addressing the causative factor in aim to limit the amount of tensile stress applied along the plantar fascia.

  • Good footwear can be used as a control point but also for shock absorption
  • Muscular issues may be resolved with stretching/strengthening programs
  • Certain foot types or hypermobile feet may be controlled with Orthotic therapy
  • Shock wave therapy may be used to aid any chronic cases into an acute phase – decreasing healing times.