Plantar Heel Pain

What is Plantar Heel Pain?

Plantar heel pain, which is pain in the bottom of your heel, is a common issue among adults. It can cause a lot of discomforts, making everyday activities difficult. This heel pain can happen because of a few different things. It could be a condition in the heel itself, like plantar fasciitis (inflammation of a band of tissue that runs across the bottom of your foot), or the thinning of a fat pad in your heel. Other causes could be a stress fracture in your heel bone, or the trapping of certain nerves in this area.

Sometimes, the pain isn’t sourced in the heel but is coming from somewhere else, such as radiculopathy (pinched nerve) in the lower part of the spine. It can also be a sign of certain systemic illnesses, which affect the entire body, such as spondyloarthropathies (a group of diseases causing inflammation in the joints).

To make a diagnosis, doctors will usually talk to you about your symptoms and examine your foot. Special laboratory tests could be done to check for systemic causes. Scans, such as plain radiographs (X-Rays) and computed tomography (CT scans), help confirm stress fractures and detect bone tumors. High-resolution ultrasound can confirm plantar fasciitis, heel fat pad atrophy (thinning), or nerve entrapments.

When necessary, doctors perform electrophysiological studies, which check for problems with nerve signaling. They may also use magnetic resonance imaging (MRI), which is better than ultrasound at viewing bone-related issues and also detects issues in soft tissues.

Once a diagnosis is made, several treatments can help with the pain. Changes in lifestyle, medications like non-steroidal anti-inflammatory drugs, rehabilitation exercises, local injections, and if necessary, surgery, are all available treatment options.

What Causes Plantar Heel Pain?

There are various reasons you might be experiencing heel pain. Here are some of them:

Local causes – these are problems that originate in the foot itself:

• Mechanical: An inflammation of the tissue that connects your heel to your toes, called plantar fasciitis
• Traumatic: Calcaneal stress fractures, or small cracks in the heel bone due to overuse or repetitive activity
• Neurologic: Nerve issues like the tibial nerve being squeezed causing a condition called posterior tarsal tunnel syndrome, or problems with the medial calcaneal or Baxter nerves
• Other: Things like tumors, a bone infection called osteomyelitis, warts on the bottom of the foot, or thinning of the fat pad that cushions the heel

Referred causes – these are pains that originated elsewhere in the body but are felt in the heel:

• S1 radiculopathy: A problem with the S1 nerve root that causes pain or numbness in the foot or heel

Systemic causes – these are conditions that affect the entire body:

• Rheumatoid arthritis: An autoimmune disease that can cause inflammation in various joints, including the heel
• Seronegative spondyloarthropathies: A group of diseases that cause inflammation in the spine and other joints

And certain risk factors can increase your likelihood of developing trouble with your heel, including:

• Obesity: Being overweight puts more strain on the structures of the feet
• Prolonged standing: Standing for long periods can lead to foot or heel pain
• Inappropriate footwear: Wearing shoes that do not support or cushion your feet properly can contribute to heel pain

Risk Factors and Frequency for Plantar Heel Pain

In the United States, over a million doctor visits are made each year due to a condition known as plantar heel pain. This issue affects both active people and those who lead a less active lifestyle. Both men and women are equally susceptible to this condition. The most common reason for heel pain is something called plantar fasciitis, which affects about 2 million Americans annually. It’s estimated that almost 10% of the population will experience this condition at some point in their lives.

• Heel pain is also linked to stress fractures in the heel bone, accounting for 20% of all lower body stress fractures in a study of over 109,296 soldiers.
• In 16% of heel pain cases, the patient also has a systemic illness like rheumatoid arthritis.
• It’s not well understood how often nerve-related issues cause plantar heel pain.

Signs and Symptoms of Plantar Heel Pain

There are various health conditions that can cause heel pain. Each presents with specific symptoms such as pain in different regions of the heel or foot and different types of pain like sharp, burning, or diffused.

• Plantar Fasciitis: People often complain about heel pain when taking their first steps in the morning or after sitting for a long period. In severe cases, pain might persist even during rest and walking. Tenderness can be felt over the medial calcaneal tubercle (under the heel).
• Heel Fat Pad Atrophy: Patients experience pain in the central heel area when walking barefoot on hard surfaces. Pain can be felt on the central part of the calcaneus (the heel bone).
• Calcaneal Stress Fractures: These may result in diffused heel pain and tenderness on squeezing the heel. The pain often worsens with activity and may lead to significant bruising.
• Tarsal Tunnel Syndrome/Tibial Nerve Entrapment: This condition often shows symptoms like pain along the inside of the ankle or arch, or tingling in the foot. A tap along the tibial nerve resulting in tingling or pain, suggests tarsal tunnel entrapment.
• Medial Calcaneal Nerve Entrapment: Patients generally experience burning pain and sensation change on the skin over the calcaneus. The pain tends to be localized and does not radiate distally.
• Baxter Nerve Entrapment: This nerve entrapment may cause sharp, radiating pain along the nerve, which usually gets worse after walking or at night.
• S1 Radiculopathy: This can cause heel pain coupled with chronic lower back pain. Pain and numbness may radiate from the lower back down to the heel of the foot.
• Systemic Causes: There can also be systemic causes for heel pain that may present other symptoms like arthritis, uveitis, psoriasis, and others.

These conditions often require expert diagnosis. Details such as specific pain points, type, and timing of pain, and associated symptoms can assist healthcare professionals in determining the underlying causes of heel pain.

Testing for Plantar Heel Pain

When you experience heel pain, your doctor has several tests and tools that can help them figure out what’s causing it. First, they might take some samples of your blood to check for signs of inflammation or other markers that might point to certain diseases. They might also look at your body’s natural defense against infection, known as rheumatoid factor, antibodies which can cause problems if they turn against your body’s own tissues, and HLA-B27 which is a genetic marker often present in people with certain types of arthritis.

The next step of diagnosis could involve taking pictures of the inside of your heel. X-rays can show changes to the bone, like small growths called spurs, or signs of stress fractures. These images can also reveal things like tumors or bone cysts. Sometimes, an imaging technique called computed tomography (CT scan) might be needed to give a clearer picture, particularly if the cause of the pain is still unclear.

Ultrasound is another imaging tool that can be really useful for resolving heel pain mysteries. It can measure the thickness of a strip of tissue called the plantar fascia, which can cause pain when inflamed. Doctors can check if the fascia is over 4mm thick at its attachment point on the heel bone, which is typically associated with plantar fasciitis, a common type of heel pain. An ultrasound can also provide info about the fat pad in your heel, as well as other structures and tissues, looking for signs that might indicate a different type of arthritis, called spondyloarthropathy.

An ultrasound can also give doctors an insight into the nerves in your foot, which can sometimes be the source of heel pain. They could take measurements that might suggest specific nerve-related conditions, like tarsal tunnel syndrome. The ultrasound may also rule out other causes of pain, like tissue growths or fluid-filled sacs, known as ganglion cysts.

However, despite ultrasound’s capabilities, it’s worth noting that current guidelines don’t strongly recommend its use for heel pain or plantar fasciitis, mainly due to a lack of strong supporting evidence.

Electrical tests of your muscles and nerves can also be useful for pinpointing the location of any nerve issues, though they’re not always reliable and a good old-fashioned chat and physical examination might still provide the best clues.

Lastly, your doctor may use an imaging technique called magnetic resonance imaging (MRI). This can help when x-rays don’t show anything unusual but pain persists. MRIs provide detailed images of the various soft tissues in the heel, such as fascia, nerve, muscle and fat. Additionally, this sort of imaging can reveal hidden or underlying issues, such as bone marrow swelling that could indicate a stress fracture not visible on x-rays.

Treatment Options for Plantar Heel Pain

Plantar fasciitis is a common foot condition that causes heel pain. It can get better with some simple treatments.

The first step in treating plantar fasciitis includes methods that aim to temporarily relieve your pain and improve your foot’s flexibility. These treatments can be customized from guidelines provided by The Orthopedic Section of the American Physical Therapy Association and the Journal of Foot and Ankle Surgery. These treatments aim to address the primary cause of your heel pain.

Here’s what can help over about the first 6 weeks:

• Soft tissue massage: This can help with joint flexibility.
• Stretching exercises: For the muscles in the calf and the plantar fascia (the ligament that connects your heel bone to your toes).
• Taping: Temporary relief can be provided for up to 3 weeks.
• Orthotics: Shoe inserts and comfortable shoes may help with pain.
• Other measures: Pain relief measures like cooling therapy, anti-inflammatory medicines, weight reduction advice, restriction of certain activities and avoiding walking barefoot are also useful.

If after 6 weeks your pain still persists especially first thing in the morning, doctors often recommend:

• Night splints: These are worn at night for 1 to 3 months.
• Corticosteroid injections: However, they should not be the first-line therapy.
• Physical therapy: This can keep you on a routine and provide more targeted help.
• Electrotherapy, low-level laser therapy, or phonophoresis: These may provide some relief.
• Techniques like ultrasonic therapy and dry needling are not recommended.

If none of the above options work, then it’s time to consider some more aggressive treatments. These are typically considered if the pain has lasted for at least 6 months and other methods haven’t worked.

• Extracorporeal shockwave therapy: This method involves applying sound waves to the affected area, but it is not usually any better than the above mentioned conservative treatments.
• Surgery: If everything else fails, surgery might be considered.

Other conditions can cause heel pain too. For example, if your heel pad becomes too thin (atrophy), the treatment focuses on relieving symptoms, such as resting, using ice, taking anti-inflammatory drugs, foot supports, and avoiding high-impact activities.

Stress fractures in the heel bone (calcaneus) are treated with rest and avoiding the activity that caused it. A boot may be worn to restrict the movement of the foot. In severe cases, and only after other treatments have failed, surgery might be considered.

If neuromas (nerve growths) near your heel are causing the pain, doctors may treat these by suggesting nonsteroidal anti-inflammatory drugs and anticonvulsants to help reduce symptoms. If your symptoms don’t get better, your doctor may suggest a corticosteroid injection or a procedure to separate the nerve from surrounding tissues. In some cases, surgery may be necessary to take pressure off the nerve. Singer cases might need surgical decompression.

What else can Plantar Heel Pain be?

The following conditions could potentially be mistaken for each other due to their similar symptoms:

• Injuries to the Achilles tendon
• Distal plantar fasciitis (a condition causing heel pain)
• Haglund’s syndrome (a bone enlargement on the back of the heel bone)
• Plantar fibromatosis (lumps in the arch of the foot)
• Tarsal tunnel syndrome (a compression on the ankle nerve)

What to expect with Plantar Heel Pain

Plantar fasciitis generally has a good long-term outlook. Research tells us the average period of chronic heel pain can last just over a year. However, up to 90% of patients will see improvements with non-surgical, or ‘conservative’, treatments.

Patients experiencing heel fat pad atrophy (a thinning of the protective padding on the heel) often see the best improvements with a simple silicone heel cup. Meanwhile, patients who have surgery might still have some pain due to scarring.

Tarsal tunnel syndrome (a condition where a nerve near the ankle is compressed) can be more difficult to deal with. This is often because it’s hard to identify the cause and it slowly gets worse. Patient outcomes are the best when the cause or exact location of the trapped nerve is found and treated.

The outlook for a calcaneal stress fracture (a tiny crack in the heel bone) is favorable, with most patients recovering if they adjust their activities and have a period of non-weight bearing.

Possible Complications When Diagnosed with Plantar Heel Pain

For those experiencing heel pain, the usual treatments usually result in few complications. However, one of these treatments, the corticosteroid injection, could carry a slight risk of the padding at the heel wearing thin or a tear in the plantar fascia, which is a band of tissue that runs across the bottom of your foot. These risks are associated with how steroids interact with our body’s soft tissues.

Further down the line, procedures such as the plantar fascia release might carry risks including an incomplete procedure, poor blood control, or nerve damage. Similar complications can also present after a tarsal tunnel release procedure. These can include a misdiagnosis, incomplete release, formation of benign tumors in the nerve, subpar technique, poor blood control, or intrinsic nerve damage.

Surgery is usually reserved for complicated cases, such as when a heel bone, or calcaneus, stress fracture fails to heal. The surgical procedure might involve drilling into the fracture site with or without a graft. However, surgery inherently carries the most notable risks, which include swelling, pain, infection, bleeding, nerve damage, wound reopening, excessive or insufficient correction, potential need for more surgery, and blood clots.

Possible Complications:

• Sometimes ineffective corticosteroid injections
• Padding in foot getting thin or a tear in the band of tissue across the foot
• Plantar fascia release or tarsal tunnel release procedures not being fully effective
• Poor blood control or nerve damage during procedures
• Possible misdiagnosis or poor technique during tarsal tunnel release
• Surgery-related complications like swelling, pain, infection, bleeding or nerve damage
• Need for further surgery or blood clots post-surgery

Recovery from Plantar Heel Pain

Surgery is usually considered as the last resort when all other treatment options haven’t worked. After surgery, the recovery plan may differ based on the type of procedure and the patient’s objectives. Generally, stitches are removed after 2 weeks unless there are potential concerns, like slow wound healing or other health problems, that could slow down recovery. However, for cases where a second surgery is necessary, patients may not be allowed to put weight on the operation site for up to 4 weeks.

Physical therapy is also recommended to help reduce swelling and pain after surgery. It can also help restore strength and improve the sense of position or movement of the affected area (proprioception).

Preventing Plantar Heel Pain

Education is a crucial part of treatment. Talking with patients about what mainly causes their pain, how other health conditions like weight gain can affect it, what the outlook is, and how they can manage their own symptoms, helps set realistic expectations about recovery. Patients who understand where their pain comes from and what it means for their recovery are more likely to stick with the recommended treatment plans.

Plantar fasciitis, sometimes referred to as “heel spur syndrome,” is often to blame for heel pain. This pain can be caused by shoes that don’t offer enough support, standing for long periods of time, or having flat feet. The common signs of heel pain include discomfort when taking the first step in the morning or upon standing after resting for a long period of time. Foot doctors, or podiatrists, usually order foot x-rays to diagnose and identify different types of heel pain.

Treatment options can either be surgical or non-surgical. Non-surgical treatments include physical therapy, medications, injections, foot braces, and arch supports that go into the shoes. Only in severe cases, doctors recommend surgery to treat the pain.