The causes of heel pain can generally be differentiated by the site of the pain, clinical findings and the patient's status (picture 1).
In some cases, X-raying or MRI may be needed or blood samples drawn if the symptoms are suspected of being associated with an inflammatory joint disease (spondylarthropathy) or the diagnosis is unclear.
Aetiology
Degeneration of the plantar aponeurosis (plantar fasciopathy) is definitely the most common cause of heel pain in adults.
Achilles tendon problems are easy to distinguish from plantar fasciopathy based on location.
Other significantly less common causes include pain in the calcaneal fat pad, fractures (stress or osteoporotic fractures), inflammatory states associated with rheumatic diseases or spondyloarthropathy, bursitis, neuropathies and heel strain due to unsuitable footwear, walking on a hard surface or excessive strain.
Degeneration of the plantar aponeurosis (plantar fasciopathy)
Epidemiology and aetiology
The most common cause of heel pain (in as many as 80% of cases)
Affects about 10-15% of adults at some point in their lives.
A degenerative, self-limiting condition
The symptoms may persist for 12-18 months.
The condition occurs in the younger age group in people who run or participate in other sports that place strain on the sole of the foot, and it is common among middle-aged people in occupations involving prolonged standing. Being overweight adds to the risk of fasciopathy.
Often caused by strain, rarely by an inflammatory rheumatic disease.
Symptoms and findings
Pain typically occurs in the morning immediately after getting out of bed and when getting up again after sitting for a short while.
Standing or walking often make it worse. After load bearing, there may be dull pain at rest for a short while.
The pain may subside over the course of the day and get worse again towards the evening as the strain on the foot increases.
The area that is tender to palpation is typically situated anteriorly underneath the calcaneus, medially at the insertion of the plantar fascia (picture 1). Some patients also have lateral and more distal tenderness in the area of the plantar fascia. There may be some swelling in the area.
Diagnosis
Typical symptoms and a clinical examination are usually sufficient to make the diagnosis.
X-ray examination is of no diagnostic significance. Bony exostosis (spur) possibly seen in the heel bone is not associated with the condition and is normally not situated at the insertion of the plantar fascia but above it. True large exostoses, however, must be kept in mind in the differential diagnosis as a cause of heel pain, but they are very rare.
MRI is diagnostically very useful and can be done if symptoms persist, the diagnosis is not clear or the patient is worried about the condition.
Spondyloarthropathy must be excluded in patients with bilateral fasciopathy or insertional Achilles tendinitis.
Treatment
Even though plenty of different treatments have been described, there is no curative treatment available.
Padding, heel lift, calf stretching, stretching and massage of the sole of the foot, ESWT, or glucocorticoid, botulinum toxin or PRP injections may be useful in treating the symptoms.
Conservative treatment
Patients who are significantly overweight should be instructed to lose weight.
If the condition leads to incapacity for work (occupations involving prolonged standing), an attempt should be made to arrange temporarily lighter work or shorter working hours. Physical exercise causing pain should be avoided at least if the symptoms impair the patient's working ability. Rest as such provides no long-term benefit.
A night splint can be tried to increase the effect of stretching. It may help getting up in the morning, in particular, but some patients cannot sleep with a splint, and the static stretching may increase pain.
Heel padding, offloading insoles and cold and warm compresses are worth trying.
For shoes, heel lift / low heel and good shock absorption underneath the heel are recommended.
The calf and foot should be stretched daily. Stretching and massage of the sole of the foot in the morning before stepping on the foot may facilitate getting up.
In the sitting position, the foot is lifted onto the other knee and toes passively dorsiflexed so as to stretch the plantar fascia. Ten stretching exercises should be performed three times a day, the first set in the morning before taking any steps.
Taping of the heel area by a physiotherapist may be helpful.
The injection can be administered from the medial side of the heel to a depth of 2 cm at the insertion of the plantar fascia. Injecting through the sole of the foot is very painful, and some glucocorticoid may be more likely to end up in the fat pad.
If the first injection was useful, injections can be repeated at about 3-4-week intervals a maximum of 3 times, as necessary.
Degeneration of the calcaneal fat pad may occur as an adverse effect. The medication should be injected sufficiently high, not into the fat pad. The long-term benefits of injection treatment are uncertain.
Operative treatment
Surgical treatment is used very rarely. It should primarily be used in highly symptomatic cases not responding to conservative treatment and involving calf tightness.
Calf muscle release is currently recommended as surgical treatment; there is some evidence of its usefulness in the treatment of heel pain.
Nerve entrapment
Tarsal tunnel syndrome involves entrapment of the tibial nerve, causing pain and numbness medially in the ankle, in the heel and sole of the foot. There is tenderness along the nerve, and Tinel's test may produce electric shock sensations.
The entrapment is usually detected by ENMG; in addition, MRI is recommended to define the aetiology of the entrapment more specifically.
The most common causes of nerve entrapment are varicose veins and ganglia in the area of the tarsal tunnel.
Valgus positioning of the posterior foot and flatfoot predispose to the condition.
In case of entrapment of the heel nerve branch (Baxter's nerve) alone, the pain and numbness are restricted to the medial side of, and beneath, the heel. Diagnosis by ENMG is inconclusive.
The nerve should be released surgically. If the entrapment is due to a constrictive cause (such as a ganglion), the results are practically always good.
Stress fracture of the calcaneus
Requires clear, significant, extended strain or a change in the level of strain.
Occurs typically in adults who run a lot.
Occasionally seen in pregnant women.
May be more likely to occur at lower strain levels in growing children.
The calcaneus is tender on lateral pressure, and the area is swollen and feels warmer than normal.
A stress fracture is usually easy to suspect based on patient history and clinical examination.
The diagnosis is made by MRI.
Treatment consists of avoiding all pain-causing strain until the symptoms subside. Ossification of the calcaneus proceeds well provided that there is no further strain.
Symptoms at the insertion of the Achilles tendon occur behind the heel and, based on their location, are usually easy to distinguish from heel pain of other causes.
Paratenonitis and tendinosis of the Achilles tendon cause more proximal pain, thickening of the tendon and oedema in the surrounding tissue.
Pain and oedema in the tendon insertion area may be due to tendinosis, partial rupture, posterior bursitis, retrocalcaneal bursitis or friction caused by shoes.
Exostosis (Haglund's deformity) may grow on the calcaneus and cause friction but may not necessarily involve symptoms affecting the tendon itself. Haglund's deformity often causes friction problems when wearing skates, for instance; it can be removed surgically, as necessary.
Posteriorly narrow ankle and injuries to the posterior ankle should be kept in mind in differential diagnosis; patients may easily pinpoint symptoms as occurring in the Achilles tendon.
Other rare causes
Calcaneal bone cyst is a common radiological finding that is usually asymptomatic but may lead to a fracture and to pain due to pressure inside the cyst.
For osteoid osteoma and osteosarcoma, see Bone Tumours