I Have Heel Pain – What Can It Be?

The most common muskulo-skeletal ailment the doctors at Prairie Path Foot and Ankle treat is heel pain.  It is so common in all walks of life – younger patients, older patients, those that are relatively sedentary, and those that are athletes.  However it is very confusing to sort out all the different diagnosis.  So if you have heel pain, what are the different things it could be?  Proper diagnosis is a must because an accurate diagnosis will determine the treatment plan.

Plantar Fasciitis- The most typical diagnosis we see is plantar fasciitis.  The plantar fascia is a band of tissue that starts at the heel, runs across the arch, and inserts into the ball of the foot.  Pain occurs at the bottom and inside of the heel, and can also affect the arch.  Many times patients feel a lot of pain upon waking up in the morning and stepping out of bed first thing in the morning, then the pain tends to subside as the day goes on. Then every time they would sit down then stand up again, the pain cycle repeats itself.  Patients describe the pain as aching and shooting, or sometimes like a “bruise” on the heel.  This pain can come from a change in activity, increase in activity, change in shoe gear, but most commonly a lack of support of the arch.  Many times patients want to put in a heel pad because the heel hurts… but in reality, an arch support is needed.  This is because if the arch is supported, the arch will not flatten out upon standing.  The arch support actually supports the foot and prevents the stretching of the plantar fascia, and takes the pressure off of the heel.  Over time, this support decreased the pressure on the plantar fascia, thus decreasing the inflammation that occurs due to the stretching.  Other modalities that help include icing, stretching, and our MLS laser to decrease inflammation.  Custom orthotics ultimately help decrease inflammation and prevent recurrence.

Tear Of The Plantar Fascia- if plantar fasciitis goes on too long, then there could be a tear of the fascia.  The plantar fascia consists of 3 bands, and plantar fascia that has been inflamed for a long time without treatment can have so much stress upon it that it may tear.  The only way to rule out a tear is with advanced modalities, such as ultrasound or MRI.  Your doctors may take an Xray to make sure there is no bony abnormality causing the pain, however radiographs (Xrays) only show bone, they do not show soft tissue pathology. If you think you have a tear, it is important to be seen right away as delay in treatment may make it worse.  Treatment involves immobilization in a CAM walker/ walking boot.

Achilles Tendinitis -  Heel pain in the back of the heel may be indicative of Achilles tendinitis.  The achilles tendon starts in the calf muscle, or gastric, and the muscle belly becomes the Achilles tendon that inserts into the back of the calcaneus, or the heel bone.  Sometimes increase activity, a new activity, new shoe gear, or sometimes for no reason at all, the Achilles tendon becomes inflamed.  Your doctor may take radiographs in this condition to rule out any bony deformities or to see if there are any calcium deposits within the tendon or if there are spurs to the back of the heel where the tendon inserts.  If the pain does not respond to conservative therapy such as icing, bracing, stretching, and PT with MLS laser to decrease inflammation, then your doctor may order advance modalities such as an ultrasound or MRI to rule out a tear.  In order to heal a tear, immobilization is necessary and in more serious or extensive cases, then surgery may be indicated.

Plantar Heel Spur – If you have pain to the bottom of the heel and it is the central heel, it may be due to a spur.  It is important to distinguish this from plantar fasciitis, as they are not the same thing!  In fact many people who have a plantar spur do not have heel pain at all.  If it is truly the spur, this may be aggravating the bursa at the bottom of the heel, and this may in fact be a bursitis.  Treatment for this consists of icing, MLS laser for anti inflammatory effect, and accommodative orthotics to reduce the pressure on the spur.  All of these symptoms can be controlled without surgery.

Stress Fracture of the calcaneus (heel bone) – In some cases, pain in the heel is not soft tissue, but in fact the heel bone, or the calcaneus, will have a stress fracture.  A stress fracture may or may not be seen on radiographs right away, but it may be evident on radiographs 2 weeks later when the bone is reacting to the fracture. Often the way to confirm a stress fracture would be with an MRI where this would be evident with bone marrow edema, or edema within the heel bone itself.  To treat a stress fracture, you would have to be immobilized in a CAM boot/walking boot or in severe cases, a below knee cast.

Severs/Childhood heel pain/Calcaneal apophysitis- This is actually quite common in children ages 8-14, or as long as the growth plates in the heel bone are open. This is actually pain due to the tendons (in this case, the Achilles tendon) pulls on the growth plate, causing pain to the heel.  It can often be due to increased activity, improper arch support, or tightness of some of the tendons.  Treatment consists of stretching exercises to decrease the pull and pressure on the growth plate, decrease inflammation with icing, and enhancing arch support with an orthotic.  Sometimes increased stretching exercises may be warranted by the use of Physical therapy sessions, or the use of a stretching splint worn at night when the patient is nonweightbearing. Ultimately, custom orthotic are needed in order to provide arch support and decrease pressures on the heel and prevent recurrence.

If you are suffering from heel pain, it is important to be examined right away.  Remember, pain is not normal, and our doctors can help make the correct diagnosis, and come up with a treatment plan.