Zeehan S. Husain, DPM
Charles G. Kissel, DPM
Michael S. Schey, DPM
Angela
Stoutenburg, DPM
Board
certified by the
American Board of
Podiatric Surgery.
Heel Pain
Subtopics
Heel
pain is most often caused by plantar fasciitis, a condition that is
sometimes also called heel spur syndrome when a spur is present.
Heel pain may also be due to other causes, such as a stress
fracture, tendonitis, arthritis, nerve irritation, or, rarely, a cyst. Because there are several potential causes, it is important
to have heel pain properly diagnosed.
A podiatric foot and ankle surgeon is best trained to distinguish
between all the possibilities and determine the underlying source of your
heel pain. Typically, a heel
spur is seen, but the plantar fascia ligament on the bottom of the heel is
the source of the pain.
What
Is Plantar Fasciitis?
Plantar
fasciitis is an inflammation of the band of tissue (the plantar fascia)
that extends from the heel to the toes. In
this condition, the fascia first becomes irritated and then inflamed,
resulting in heel pain. The
symptoms of plantar fasciitis are:
 |
Pain
on the bottom of the heel |
|
Pain
that is usually worse upon arising |
|
Pain
that increases over a period of months |
People with plantar fasciitis often describe the pain as worse when they get up in the morning or after they have been sitting for long periods of time. After a few minutes of walking the pain decreases, because walking stretches the fascia. For some people the pain subsides but returns after spending long periods of time on their feet.
Causes
of Plantar Fasciitis
The
most common cause of plantar fasciitis relates to faulty structure or
mechanics of the foot. For
example, people who have problems with their arches, either overly
flat-footed or high-arched, are more prone to developing plantar fasciitis.
Wearing non-supportive footwear on hard, flat surfaces puts
abnormal strain on the plantar fascia and can also lead to plantar
fasciitis. This is
particularly evident when a person’s job requires long hours on their
feet. Obesity also
contributes to plantar fasciitis (body mass index).
Diagnosis
To
arrive at a diagnosis, the podiatric foot and ankle surgeon will obtain
your medical history and examine your foot. Throughout
this process the surgeon rules out all the possible causes for your heel
pain other than plantar fasciitis. In
addition, diagnostic imaging studies such as x-rays, a bone scan, or
magnetic resonance imaging (MRI) may be used to distinguish the different
types of heel pain. Sometimes
heel spurs are found in patients with plantar fasciitis, but these are
rarely a source of pain. When
they are present, the condition may be diagnosed as plantar fasciitis/heel
spur syndrome.
Treatment
Options
The
level of initial pain will influence the aggressiveness of conservative
treatment. Treatment of
plantar fasciitis begins with first-line strategies, which you can begin
at home:
|
Stretching
exercise—
Exercises that stretch out the calf muscles help ease pain and
assist with recovery. |
|
Avoid
going barefoot—
When you walk without shoes, you put undue strain and stress on
your plantar fascia. |
|
Ice—
Putting an ice pack on your heel for 10 minutes several times a
day helps reduce inflammation. |
|
Limit
activities—
Cut down on extended physical activities to give your heel a
rest. |
|
Shoe
modifications—
Wearing supportive shoes that have good arch support and a
slightly raised heel reduces stress on the plantar fascia. Your
shoes should provide a comfortable environment for the foot. |
|
Medications—
Non-steroidal anti-inflammatory drugs (NSAID), such
as ibuprofen, may help reduce pain and inflammation. |
|
Lose
weight—
Extra pounds put extra stress on your plantar fascia. |
If
you still have pain after several weeks, see your podiatric surgeon, who
may add one or more of these approaches:
|
Padding
and strapping—
Placing pads in the shoe softens the impact of walking.
Strapping helps support the foot and reduce strain on the
fascia. |
|
Orthotic
devices—
Custom orthotic devices that fit into your shoe help correct
the underlying structural abnormalities causing the plantar fasciitis. |
|
Injection
therapy—
In some cases, corticosteroid injections are used to
help reduce the inflammation and relieve pain. |
|
Removable
walking cast—
A removable walking cast may be used to keep your foot immobile
for a few weeks to allow it to rest and heal. |
|
Night
splint—
Wearing a night splint allows you to maintain an
extended stretch of the plantar fascia while sleeping.
This may help reduce the morning pain experienced by some
patients. |
|
Physical
therapy—
Exercises and other physical therapy measures may be
used to help provide relief. |
Although
most patients with plantar fasciitis respond to non-surgical treatment, a
small percentage of patients may require surgery. If,
after several months of non-surgical treatment, you continue to have heel
pain, surgery will be considered. Your
podiatric foot and ankle surgeon will discuss the surgical options with
you and determine which approach would be most beneficial for you.
Non-Conservative
Treatments
The
techniques listed below are only to be seriously considered when one has
failed conservative treatment for at least six months.
Extra-Corporeal
Shockwave Therapy
One
non-surgical option to consider is extra-corporeal shockwave therapy (ESWT)
which is commonly used for treating gallstones (lithotripsy).
This procedure is done in the office with the ESWT machine.
Patients are immobilized for two to four weeks in a walking cast.
This technique causes microtrauma to the plantar fascia to
stimulate healing.
Radiofrequency
Ablation with Platelet Rich Plasma
The
newest surgical technique involves radiofrequency ablation of the plantar
fascia with the use of platelet rich plasma being injected into the area
of pain. The procedure is done in the operating room with multiple
needle sized pokes into the heel and plantar fascia.
The plantar fascia is then microdebrided with the radiofrequency
ablator through these holes. The
patient’s blood is taken pre-operatively and the growth factors from the
blood are spun down into a liquid form which concentrates the materials
needed to boost healing. This
is simply injected into the area of pain along the plantar fascia.
No sutures are needed. Patients
are immobilized for two to four weeks in a walking cast.
Endoscopic
Plantar Fasciotomy
Endoscopic
plantar fasciotomy is a minimally invasive surgical technique for the
alleviation of pain associated with plantar fasciitis that has failed all
conservative treatment. The
procedure was developed to partially release the plantar fascia to allow
it to stretch in a less traumatic and controlled manner. The
new technique allows for a quicker recovery and a faster return to normal
activity. The procedure
involves an outpatient surgical visit utilizing specially designed
instruments that allow the surgeon to directly visualize the foot
structures on a video screen while only making one small incision on the
foot. Cast immobilization can
be implemented for two to six weeks.
Everyone heals slightly differently. Other
factors such as age, weight, and occupation can contribute to healing
times.
Long-Term
Care
No
matter what kind of treatment you undergo for plantar fasciitis, the
underlying causes that led to this condition may remain. Therefore,
you will need to continue with preventive measures. If you are overweight, it is important to reach and maintain
an ideal weight. For all
patients, wearing supportive shoes and using custom orthotic devices are
the mainstay of long-term treatment for plantar fasciitis.
Heel
pain is a common childhood complaint.
That does not mean, however, that it should be ignored, or that
parents should wait to see if it will “go away”.
Heel pain is a symptom, not a disease. In
other words, heel pain is a warning sign that a child has a condition that
deserves attention. Heel pain
problems in children are often associated with these signs and symptoms:
|
Pain
in the back or bottom of the heel |
|
Limping |
|
Walking
on toes |
|
Difficulty participating in usual activities or sport |
The most common cause of pediatric heel pain is a disorder called calcaneal apophysitis, which usually affects 8- to 14-year olds. However, pediatric heel pain may be the sign of many other problems, and can occur at younger or older ages.
What
Is the Difference Between Pediatric and Adult Heel Pain?
Pediatric
heel pain differs from the most common form of heel pain experienced by
adults (plantar fasciitis) in the way pain occurs.
Plantar fascia pain is intense when getting out of bed in the
morning or after sitting for long periods, and then it subsides after
walking around a bit. Pediatric
heel pain usually doesn’t improve in this manner. In
fact, walking around typically makes the pain worse.
Heel
pain is so common in children because of the very nature of their growing
feet. In children, the heel
bone (the calcaneus) is not yet fully developed until age 14 or older. Until then, new bone is forming at the growth plate (the
physis), a weak area located at the back of the heel.
Too much stress on the growth plate is the most common cause of
pediatric heel pain.
Causes
of Pediatric Heel Pain
There
are a number of possible causes for a child’s heel pain. Because diagnosis can be challenging, a podiatric foot and
ankle surgeon is best qualified to determine the underlying cause of the
pain and develop an effective treatment plan.
Conditions that cause pediatric heel pain include:
|
Calcaneal
apophysitis—
Also known as Sever’s disease, this is the most common cause
of heel pain in children. Although
not a true “disease,” it is an inflammation of the heel’s growth
plate due to muscle strain and repetitive stress, especially in those
who are active or obese. This condition usually causes pain and tenderness in the back
and bottom of the heel when walking, and the heel is painful when
touched. It can occur in
one or both feet. |
|
Tendo-Achilles
bursitis—
This condition is an inflammation of the fluid-filled sac
(bursa) located between the Achilles tendon (heel cord) and the heel
bone. Tendo-Achilles
bursitis can result from injuries to the heel, certain diseases (such
as juvenile rheumatoid arthritis), or wearing poorly cushioned shoes. |
|
Overuse
syndromes—
Because the heel’s growth plate is sensitive to repeated
running and pounding on hard surfaces, pediatric heel pain often
reflects overuse. Children and adolescents involved in soccer, track, or
basketball are especially vulnerable. One
common overuse syndrome is Achilles tendonitis.
This inflammation of the tendon usually occurs in children over
the age of 14. Another
overuse syndrome is plantar fasciitis, which is an inflammation of the
band of tissue (the plantar fascia) that runs along the bottom of the
foot from the heel to the toes. |
|
Fractures—
Sometimes heel pain is caused by a break in the bone.
Stress fractures,
hairline breaks resulting from repeated stress on the bone,
often occur in adolescents engaged in athletics, especially when the
intensity of training suddenly changes. In children under age of ten, another type of break, acute
fractures, can
result from simply jumping two or three feet from a couch or stairway. |
Diagnosis
of Pediatric Heel Pain
To
diagnose the underlying cause of your child’s heel pain, the podiatric
surgeon will first obtain a thorough medical history and ask questions
about recent activities. The
surgeon will also examine the child’s foot and leg. X-rays
are often used to evaluate the condition, and in some cases the surgeon
will order a bone scan, a magnetic resonance imaging (MRI) study, or a
computerized tomography (CT or CAT) scan. Laboratory
testing may also be ordered to help diagnose other less prevalent causes
of pediatric heel pain.
Treatment
Options
The
treatment selected depends upon the diagnosis and the severity of the
pain. For mild heel pain,
treatment options include:
|
Reduce
activity—
The child needs to reduce or stop any activity that causes
pain. |
|
Cushion
the heel—
Temporary shoe inserts are useful in softening the impact on
the heel when walking, running, and standing. |
For
moderate heel pain, in addition to reducing activity and cushioning the
heel, the podiatric surgeon may use one or more of these treatment
options:
|
Medications—
Non-steroidal anti-inflammatory drugs (NSAID), such as
ibuprofen, help reduce pain and inflammation. |
|
Physical
therapy—
Stretching or physical therapy modalities are sometimes used to
promote healing of the inflamed tissue. |
|
Orthotic devices— Custom orthotic devices prescribed by the podiatric surgeon help support the foot properly. |
For
severe heel pain, more aggressive treatment options may be necessary,
including:
|
Immobilization—
Some patients need to use crutches to avoid all weight-bearing
on the affected foot for a while. In
some severe cases of pediatric heel pain, the child may be placed in a
cast to promote healing while keeping the foot and ankle totally
immobile. |
|
Follow-up
measures—
After immobilization or casting, follow-up care often includes
use of custom orthotic devices, physical therapy, or strapping. |
|
Surgery—
There are some instances, very rarely, when surgery may be
required to lengthen the tendon or correct other problems. |
Can
Pediatric Heel Pain Be Prevented?
The
chances of a child developing heel pain can be reduced by following these
recommendations:
|
Avoid
obesity |
|
Choose
well-constructed, supportive shoes that are appropriate for the
child’s activity |
|
Avoid,
or limit, wearing cleated athletic shoes |
|
Avoid
activity beyond a child’s ability |
If
Symptoms Return
Often
heel pain in children returns after it has been treated because the heel
bone is still growing. Recurrence
of heel pain may be a sign of the initially diagnosed condition, or it may
indicate a different problem. If
your child has a repeat bout of heel pain, be sure to make an appointment
with your podiatric surgeon.
