Heel pain affecting the bottom of the heel is usually caused by inflammation of the plantar fascia, a condition called plantar fasciitis. Chronic inflammation of the plantar fascia may cause bone spurs on the bottom of the heel. Bone spurs are a bony reaction from excessive pulling of the plantar fascia. Bone spurs typically do not hurt unless they are fractured. Other causes of heel pain may include stress fracture, tendonitis, arthritis, cysts, or referred nerve pain. A doctor at Weil Foot & Ankle can help determine the underlying source of your heel pain and guide towards the appropriate treatment options.
Plantar fasciitis is an inflammation of the band of tissue (the plantar fascia) that extends from the bottom of the heel to the toes. This pain may start abruptly due to ligament injury or gradually over time with overuse, weight gain, muscle imbalance, change in activity or wearing shoes with minimal support.
What is Haglund’s deformity?
Heel pain occurring on the back of the heel may be caused by a bony growth known as “Haglund’s deformity”. These bony growths typically form from excessive pulling from the Achilles tendon; this typically is caused by tight calf muscles or hamstrings. Haglund’s deformity refers to the presence of a large bump on the back of the heel that rubs against the shoe, causing pain and irritation. It may also rub against the Achilles, causing irritation and damage to the tendon.
Plantar fasciitis is often caused by biomechanical factors including flat arches, tight calf muscles and muscle imbalance. Wearing non-supportive footwear on hard, flat surfaces can lead to plantar fasciitis by putting extra strain on the plantar fascia. This can be exacerbated if you are overweight or have a job that requires you to spend a great deal of time on your feet. Nerve problems frequently mimic the signs and symptoms of plantar fasciitis. This can be difficult to detect during a routine physical examination, and may require electrodiagnostic nerve tests to confirm the presence, location, and degree of a nerve injury.
The symptoms of plantar fasciitis are:
- Pain on the bottom of the heel
- Pain that is usually worse with the first few steps in the morning
- Pain that worsens after periods of activity
- Pain that gradually increases and worsens with time and activity
- Pain aggravates with barefoot walking, or walking on flat surfaces
People with plantar fasciitis most often describe worsening pain when they take the first steps in the morning or periods of rest after activity. As the plantar fascia stretches with walking throughout the day, the pain may improve.
There are a number of factors which may put you at a higher risk of plantar fasciitis.
- Foot shape: Irregularities in the shape of your foot, such as high arches, can cause extra stress and strain on the plantar fascia. The shape of your foot plays a big role in the biomechanics of your foot in gait.
- Too much time on your feet: Whether it’s jogging, walking long distances, or working at a job that requires a lot of time spent on your feet, overuse is one of the leading causes of plantar fasciitis.
- Sedentary lifestyle: Overuse can contribute to injuries, but so can underuse. If you live an inactive lifestyle, there is a risk of your plantar fascia becoming weaker and less flexible, leading to increased risks of injury when stress is applied.
- Obesity: The plantar fascia experiences more strain when it has to accommodate more weight. Being overweight or obese poses higher risks of arch collapse which ultimately puts more stress on the plantar fascia.
Plantar fasciitis can be diagnosed by reviewing the patient’s medical history, performing a thorough physical and biomechanical examination of the foot and ankle and obtaining x-rays. In some cases, other imaging modalities such as ultrasound or MRI may be used to identify heel spurs or soft tissue problems that could be contributing to pain.
Treatment of plantar fasciitis begins with first-line strategies that support, stretch and strengthen the foot and lower extremity:
- Stretching exercises: Exercises that stretch out the calf muscles can help ease pain and reduce stress on the plantar fascia.
- Avoid barefoot walking: When you walk barefoot or use non-supportive slippers or shoes you place undue strain and stress on your plantar fascia resulting in injury.
- Ice: Icing your heel for 10 minutes, several times a day helps reduce inflammation and pain. Place a thin towel between the ice and your heel; do not apply ice directly to the skin as this may cause a freeze burn.
- Limit activities: Reduce the amount of extended physical activities to give your heel some rest.
- Shoe modifications: Wearing supportive shoes that have good arch support and a slightly raised heel reduces stress on the plantar fascia.
- Medications: Oral non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, are recommended to reduce pain and inflammation. (Remember, Acetaminophen is a pain reliever but it is NOT an anti-inflammatory.)
If your pain persists after several weeks, it is advised to seek medical evaluation by a Weil Foot and Ankle physician, who will discuss further treatment options with you:
- Padding and strapping: Placing pads on the foot or 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 support your arches and help correct underlying structural abnormalities that often cause plantar fasciitis.
- Injection therapy: In some cases, corticosteroid injections and OrthoBiologics are used to help reduce the inflammation and relieve pain.
- Removable walking cast: A removable walking cast may be used to immobilize your foot 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 will help reduce the morning pain experienced.
- Physical therapy: Exercises and other physical therapy measures may be used to help provide relief.
When Is Surgery Needed for Heel Pain?
Although most patients with plantar fasciitis respond to non-surgical treatment, a small percentage of patients require surgery. If after several months of non-surgical treatment, you continue to have heel pain, surgery will be considered. Your foot and ankle surgeon will discuss surgical options with you and determine which approach would be most beneficial for you.
Long-Term Care for Heel Pain
Despite the 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. Wearing supportive shoes, stretching, and using custom orthotic devices are the mainstay of long-term treatment for plantar fasciitis.
Wearing proper shoes and custom orthotics that provide proper arch support can help you avoid plantar fasciitis and other foot injuries. You should avoid over-training or “playing through the pain” if you begin to experience heel pain during physical activity. Avoid walking barefoot and always wear supportive shoes. Stretching is very important when it comes to maintaining plantar fascia health and flexibility. Your podiatrist can demonstrate stretches for you and may recommend physical therapy for more detailed training.
If not treated, plantar fasciitis can lead to increased heel pain and complications which may render conservative treatments ineffective, necessitating surgery. It can also lead to pain in the hips, back, and knees, as other muscles need to compensate to correct for heel dysfunction during regular activities like standing and walking.
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