Heel pain is something that we treat regularly in our clinic and it occurs in a significantly large percentage of the population. Up to 10% of Canadians complain of various types of heel pain each year. Often people hear different theories as to what is creating their pain and what type of treatment they should receive to alleviate their symptoms. In this article the most common types of heel pain are described as well as how they originate and strategies for treatment.
Pain Underneath the Heel
Plantar fasciitis is the most common type of heel pain that we see in clinic. This pain precipitates when the thick fascial band that runs from the base of our heels to the base of our toes becomes overloaded. Most commonly the attachment of this band where it originates on the underside of our heel becomes inflamed resulting from an increase in the forces running through it. This sharp pain is felt at the base of the heel and is often most painful in the morning or after not moving for a period of time but generally improves with activity as the tissue warms up. This condition does progress however wherein heel pain is felt initiating activity and eventually even throughout the entire activity and continuing afterwards. The most common causes of this syndrome include: poor calf flexibility (limiting movement of foot & toes upward); weight gain; high arches; inappropriate footwear (poor support of arch); prolonged barefoot standing or walking; weakened foot muscles; sudden increase in activity; and high impact activity (running/jumping).
Treatment of plantar fasciitis includes:
Early intervention to reduce pain and inflammation
Regain normal length of calf and foot muscles
Restore foot/arch muscle control
Restore proper foot biomechanics and running technique
Introduction of proper footwear specific to the individuals anatomy and sport
Controlled return to sport
Shockwave therapy has been shown to be an effective modality to treat chronic plantar fasciitis. The acoustic pulses of high energy delivered during treatment have been shown to aid in: formation of new blood vessels; stimulation of local collagen; reversal of chronic inflammation; and dissolution of calcium deposits.
Heel spurs can occur when plantar fasciitis persists for a prolonged period of time. For the initial six weeks of injury, the body will try to heal this damaged tissue with fibroblastic activity (soft collagen tissue being laid down) but after this time period osteoblastic activity (bone formation) can ensue. Slowly over the next few months bone spurs can start to develop at this site of chronic inflammation. It should be noted that heel spurs could also be a result of a sudden single compression trauma such as a hard landing onto the heel or repetitive hard trauma to the heels.
Treatment for heel spurs follows the same guidelines as plantar fasciitis. Even though the heel spur may still appear on x-ray, once the local inflammation adjacent to the heel spur is resolved, the heel pain will disappear. Heel pads may also help in cushioning the load to this localized point of pain.
Pain Behind the Heel
Achilles tendinopathy presents as heel pain at the back of the heel where the Achilles tendon inserts into the calcaneous. It generally results from overuse of this tendon and is very common in runners and jumpers. It is often felt as a burning pain at the initiation of activity but will lessen during activity and then worsen again after the activity. The Achilles may be tender and warm and could present with a nodule or bump at affected area. This area can feel quite stiff and sore on rising out of bed in morning. The most common risk factors for this syndrome include: over-training (increased distance, frequency or speed work); hill running; poor footwear; change in training surface; higher body weight; age>30; stiff ankle joints; or weak or tight calf muscles. There are three main stages of an Achiles tendinopathy; the acute or reactive phase , the more chronic dysrepair phase and finally the degenerative phase.
Treatment of Achilles tendinopathy is very specific to the stage of the injury and of course early intervention is key to preventing further damage to this tendon complex. Risk factors must be examined and addressed including: modification of activities; muscle length concerns; introduction of proper footwear etc. Therapy initially focuses on minimizing pain in this area while slowly restoring normal function via controlled tendon loading exercises.
Shockwave therapy has also been shown to be effective in treating a chronic Achilles tendinopathy. As mentioned above, it can assist in creating new blood supply and collagen tissue thus allowing an increased healing response in the damaged area.
Retrocalcaneal Bursitis can often be mistaken for an Achilles injury but also the two injuries can occur in tandem. This bursa is a fluid-filled sac that lies between the Achilles tendon and the heel bone to help prevent friction between the two structures. With this type of bursitis the rear heel area will be swollen and very tender to the touch making any tight-fitting shoes extremely painful to wear. Irritation and subsequent inflammation of this bursa can be a result of various factors such as poor fitting shoes or skates, a tight Achilles tendon or increased movement or load through the tendon (e.g hill running).
Treatment for Retrocalcaneal Bursitis:
Rest/modification of activities
Modification of footwear
Heel pads or cups
Stretching of Achilles tendon
This article shows that there are many different types of heel pain including others not mentioned above. With all of the injuries mentioned, early intervention, thorough assessment and a specific management plan are critical in ensuring a timely and successful recovery are achieved.
Karen Nichol, founder of Royal City Physio, graduated from the University of British Columbia with a Bachelor of Science in Physiotherapy. She is currently the head physiotherapist for Coquitlam Adanac Sr A's Mens Lacrosse and Team Canada Lacrosse. She is also a member of the Canadian Physiotherapy Association, and the Physiotherapy Association of B.C. Book with Karen today.