Our feet are designed to act as shock absorbers and are able to handle very heavy loads. We often push past the limit by running or playing sports on very hard surfaces or wearing shoes / flip-flops that are not supportive or are of improper size leading to a multitude of foot and ankle problems.
The most common foot and ankle complaint of those presenting to The Foot & Ankle Center, PC in Pooler GA, and to foot & ankle specialists nationally, is heel pain. It can also be one of the most complex problems to treat because of the multiple causes as well as the typical delay in seeking treatment. When the early signs of heel pain are ignored the symptoms usually get worse and may often lead to other foot and ankle problems caused by compensation.
There are two categories of heel pain: pain on the bottom (plantar) and pain on the back of the heel bone (calcaneus). The most common cause pain on the bottom of the heel is plantar fasciitis or better known as heel spur syndrome. Another common cause is nerve entrapment (~70% of patients have both plantar fasciitis and nerve entrapment) and less commonly, stress fracture, arthritis, tendonitis, a cyst or a combination of these. Pain on the back of the heel most often involves the insertion of the Achilles tendon into the bone. Due to the multi-factorial nature of heel pain, the earlier a diagnosis is made, the better the outcome.
Causes of Heel Pain:
Plantar Fasciitis / Heel Spur
A sharp stabbing pain, like a nail going into the bottom of the heel when first stepping on the foot after getting out of bed or after sitting for period of time, is the most common description for plantar fasciitis or heel spur syndrome. Typically the pain eases off as the day goes on but it may not go away completely. A thick ligament that attaches to the bottom of the heel and runs the length of the foot to the toes can become inflamed and swollen at the attachment site. This tends to be an overuse type of injury where poor foot structure is involved; also, wearing of shoe gear that lacks adequate support (ie: worn out shoes, boots and flip-flops) and prolonged standing or walking are often implicated.
A throbbing pain that gets worse as the day goes on and can be worse at night when laying in bed is most often associated with an irritated or entrapped nerve on the inside of the ankle or heel. This is similar to carpel tunnel syndrome in the wrist and hand. Approximately 7 / 10 patients with heel pain have a component of nerve entrapment as the cause of their heel pain. This is also one of the most common causes of chronic heel pain because it is often missed as a diagnosis. When nerve entrapment is considered to be a cause, painless neurosensory testing is performed with the Pressure Specified Sensory Device™ (PSSD) at The Foot & Ankle Center, PC to determine the extent of compression.
A less common cause of heel pain but a stress fracture is often considered in athletes, such as long distance runners, who have heel pain.
Posterior Heel Pain (Retrocalcaneal)
This is pain in the back of the heel that flares up when first starting an activity. It is often associated with a large bump that can be irritated by shoes. The Achilles tendon attaches to the back of the heel and, like on the bottom, this attachment site can often become inflamed; a spur may or may not be present. Another painful area is a sac of fluid (bursa) that sits between the tendon and bone to act as a cushion for the tendon. This bursa can become inflamed often leading to significant pain called retrocalcaneal bursitis.
When to seek medical attention:
Treatment of heel pain must be directed at the specific cause of your problem. If you are unsure of the cause of your symptoms, or if you do not know the specific treatment recommendations, you should seek medical attention. You should call Dr. Talarico for an appointment if you experience any of the following:
- Inability to walk comfortably on the affected foot
- Persistent, throbbing pain in the heel that occurs at night or while resting
- Heel pain that persists beyond a few days
- Swelling or discoloration in the heel area
- Redness, warmth or other signs of infection in the heel
- Any other unusual symptoms
Treatments for heel pain:
The proper treatment for your heel pain depends entirely on the specific cause(s) of your symptoms. Therefore, it is critical to understand the cause(s) of your symptoms before beginning any treatment program and if you are unsure, then seeking medical advice is essential to develop the proper treatment program for your condition.
Some common treatments are listed and can be performed at home. Keep in mind that not all of these treatments are appropriate for every condition, but they usually a good place to start.
- Rest – reducing activities for a few days can help to reduce the most severe pain.
- Ice – applying ice to the heel for 10 minutes several times a day will help to reduce inflammation.
- Stretching exercises – to lengthen the muscles in the back of the leg, including the hamstrings, will help to ease pain, reduce focal pressures to your feet and assist in recovery. For plantar fasciitis, this may be the best treatment of all.
- Avoid going barefoot – when without shoes excessive stress and strain is placed on the plantar fascia.
- Proper shoe gear – supportive shoes that fit and are not too worn along with good arch support help to reduce the stress and strain on the plantar fascia over time.
- Medications – non-steroidal anti-inflammatory medication, such as Motrin (ibuprofen), may help to reduce inflammation.
If the pain persists or worsens after a couple of days, an appointment may be necessary where Dr. Talarico may add one or more of these additional modalities to your treatment program:
- Orthotic devices – whether pre-fabricated or custom orthotic is used, these devices can help reduce the underlying structural abnormalities of the foot which have lead to the development of plantar fasciitis. These are often used to limit the recurrence of plantar fasciitis pain.
- Strapping – a special taping technique to help reduce the strain on the fascia.
- Injection therapy – in some instances injections are used to reduce the inflammation and reduce pain.
- Night Splint – this allows you to maintain an extended stretch on the plantar fascia while sleeping. Over time, this has shown to reduce the morning pain which some people experience.
- Removable Walking Cast – in some case of severe heel pain this may be used to keep your foot immobile for a few weeks allowing it to rest and heal.
- Physical Therapy – may be recommended to aid in pain relief. At The Foot & Ankle Center, PC, Dr Talarico will often utilize two additional in-office modalities, EPAT and MLS Laser Therapy , which are very effective in treating most inflammatory conditions of the foot and ankle, including plantar fasciitis.
When a diagnosis of plantar fasciitis is made early, most patients respond to conservative treatment and don’t require surgical intervention. Often, when there is a secondary diagnosis contributing to your pain, such as an entrapped nerve , and you are non-responsive to conservative care, surgery may be considered. Dr. Talarico will discuss all options and which approach would be the most beneficial for your condition.
Long Term Care of Your Heel Pain:
It is important to keep in mind that even if heel pain is resolved, it may return. Therefore, continuing with preventative measures such as proper shoe gear, stretching exercises and using a custom orthotic will help reduce the likelihood of its return.