Heel Pain

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.

• 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 effect of analgesics is often poor.

• Glucocorticoid/local anaesthetic injections Glucocorticoid Injection at the Insertion of the Plantar Fascia (such as methylprednisolone acetate 40 mg/ml depot injectable suspension, 1-2 ml) are usually most readily available. They alleviate the symptoms for an average of 4 weeks.
  • 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.

• 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.