Heel Pain

Heel pain is one of the most common presenting complaints seen. It has been estimated that 15 percent of all adult foot problems are due to discomfort in or around the heel. Many runners and non-runners alike develop overload stress syndromes, with a number of these problems occur ring in the heel. Typically we think of a heel spur or inflammation of the ligament in the bottom of the foot where it attaches to the heel as the cause of the pain. Heel pain, however, can be caused by abnormalities in almost any bodily system including: renal, endocrine, musculoskeletal, circulatory, and nervous. It can also be related to defects in biomechanical functions and errors in metabolism. Indeed, the cause of heel pain may be as numerous as the theories used over the years to explain them. A recent study confirmed that 80 to 85 percent of all heel pains are secondary to mechanical causes because of the abnormal function of the structures in the legs and feet.

The causes of heel pain are best discussed by referring to the four areas in the heel complex where they most often occur. They are planter (bottom), medial (inside), lateral (outside) and posterior (back or heel cord area). In our discussion of these areas we must also review the anatomy of the heel area.

The heel bone is the largest bone in the foot. It bears all the body's weight at heel contact. To aid in absorbing the stress at impact, there is a pad of tissue under the heel composed of fatty tissue and elastic fibrous tissue enclosed within compartments formed by strong fibrous divisions. Mother Nature also has formed structures called bursa to help absorb shock. These little fluid filled sacs occur on the bottom of the heel, and in front and in back of the attachments of the Achilles tendon which attaches to the back of the heel. Attached to the bottom of the heel are muscles which govern the movement of the toes, and strong fibrous ligaments which run from the heel to the bones in the ball of the foot. All of these structures are affected by the shape and function of the bones that make up the feet and legs, and by the stress upon them caused by overuse from excessive pressure. This excessive pressure can be caused by overuse or stress from athletics or even by carrying too much body weight.

Plantar Heel Pain
The most common area for pain in the heel is on the bottom or planter aspect. There are three main conditions seen: one, plantar fasciitis; two, heel spurs; and three, a painful heel pad or bursitis.

Plantar fasciitis is an inflammation of the ligaments where they attach to the heel. When the small foot muscles are also inflamed the condition is termed "plantarmyo fasciitis" Typically it is caused by proration or flattening of the arch of the foot. Abnormal forces cause the arch of the foot to depress or lower. This puts a strain on the ligaments which pull away at their attachment to the heel. The heel bone is covered with an onion like structure called the periosteum. It has nerves in it that get irritated by this pulling action and pain results.

A heel spur is an outgrowth of bone on the bottom of the heel that is caused by excessive pressure over a long period of time. It appears on x-ray examination as a small pencil-point of bone but it is really a shelf of bone that extends along the entire bottom of the heel.

The heel pad, as previously discussed, helps absorb shock. Young tissue has an elasticity which decreases with age and increased weight. If it decreases too much, there is pain. The bursa in the area used to absorb shock also get inflamed and this is termed "bursitis."

I like to lump the three aforementioned conditions into what I term a heel spur syndrome; plantar fasciitis, bursitis, and a heel spur. This collection of symptoms usually occurs as a unit. A typical history from the patient is that of pain in the heel with stepping out of bed in the morning or after sitting for a period of time, then getting up. The symptoms tend to disappear after 15 or 20 steps. Examination reveals the area of maximum tenderness to be mainly on the medial or inside bottom of the heel. This is because of the increased stress on the most medial portion of the ligament and the fact that anatomically the inner most aspect of the heel bone is larger than the outer side. There may also be pain on the bottom center of the heel which is the inflamed bursar sac. X-rays may reveal a spur on the bottom of the heel. Over 50 percent of the patients examined will have this spur; however, the significance of its presence is debatable since many such patients may have a spur on the other heel without any of the same symptoms. In fact, we frequently find spurs on the heels as an incidental finding as part of an examination for a totally unrelated condition.

Our first line of treatment is always conservative. It involves the use of a heel pad, inserts, or orthotic to control the flattening of the foot and to absorb shock. Two excellent products available over the counter are the Sorbothane heel pad, whose internal design closely resembles that of the natural heel pad, and Spenco, which is a nitrogen-impregnated material that absorbs shock and shearing forces. Many types of heel cups are also available. Systemic non-steroidal anti-inflammatories are sometimes successful al though I prefer to use an injection of cortisone mixed with some local anesthetic. This usually is very effective in relieving the inflammation caused by the inflamed fascia and bursa. However, it does not dissolve the spur. A series of injections are given but not more than three within a six-month period. This type of therapy usually gives dramatic relief. In some individuals, however, surgery is necessary. I prefer to use a small incision on the medial or inside of the heel. This approach has proven to be better than the outside or bottom approach because it is less painful, avoids important nerves being injured, and usually heals well. Recovery usually takes six to eight weeks, although it may be several more months before all symptoms are gone.

A promising new method of treatment for heel spurs is by means of drilling seven to ten holes in the heel from the inside to outside of the bone just above where the spur has grown. Disability time is dramatically reduced, the success rate is over 90 percent, and it appears to be an excellent procedure for mechanically-induced spur formation.

Medial Heel Pain
Medially we see several common conditions. They are: tarsal tunnel syndrome or compression of the posterior tibial nerve, heel neuromas, and posterior tibial Tendonitis.

In back of the bone on the inside of the ankle and on the inside of the heel is a tunnel for passage of a large nerve that sends off branches to three areas; the inside of the foot, the outside of the foot and the inside of the heel. Overlying this nerve is a strong ligament. When the foot has a tendency to flatten this ligament tightens and compresses the nerve under it. This causes pain which extends from that area to the inside of the arch of the foot. The condition is very similar to one seen commonly in the wrist called carpal tunnel syndrome. Sometimes electrical nerve conduction tests are used to help diagnose the entrapment. These tests however may be negative in 50 percent of the cases where true nerve entrapment does exist. Treatment is to sup port the foot structure against flattening, use anti-inflammatories, or perform a surgical procedure that releases the pressure on the nerve. This involves incising the ligament and is very effective in curing the problem.

A heel neuroma is an enlargement of that part of the nerve that splits off and sends a branch into the inner aspect of the heel. Typically, the pain is described as a burning sensation and follows a course consistent with the distribution of the nerve itself. It is aggravated by long periods of standing but still may hurt even when off the affected foot, although to a lesser degree. It is important to determine the difference between this condition and the tarsal tunnel syndrome. Sometimes the enlarged nerve can be felt or rolled back and forth under your fingers. Treatment is again either anti-inflammatories, control of the proration, or surgical sectioning of the nerve. It is important to point out that the nerve is a sensory nerve and not a motor nerve. It allows us to feel yet does not affect our ability to move the heel. Therefore, surgical excision or sectioning will not produce ill effects other than some numbness in the area. This, of course, is better than having pain!

The posterior tibial tendon originates on the inner aspect of the shin bone (tibia), courses in back of the inside of the ankle bone, and attaches into the area of the arch. Its function is to pull the foot down and inward. Flat feet can cause a tremendous strain of this important muscle/ten don complex and it often causes pain on the inner aspect of the heel. We frequently see it occur in runners with proration problems and I refer to it as a type of shin splint. The best treatment is to correct the proration or flattening and the symptoms rapidly disappear. This tendon may also partially or completely rupture and be quite disabling. The diagnosis is usually straight -forward because of its location and associated distribution of pain with loss of function. Surgical correction is usually indicated for ruptures.

Lateral Heel Pain
There are two conditions found on the outside of the heel that can cause pain. The first and most common is inflammation of the peroneal tendon. The other which is far less frequent is entrapment of the sural nerve.

There are two peroneal tendons that course from the outside of the lower leg, pass in back of the outside bone of the ankle, cross the heel and attach into the foot. Like the posterior tibial tendon already discussed, these can become in flamed and need medical management. I have had two cases in which the patient complained of pain on the outside part of the heel which resulted in a final diagnosis of a rupture of one of the tendons, the peroneus brevis. This type of rupture is very rare and requires surgical repair.

The sural nerve, like the posterior nerve, sends its branches to the outermost aspect of the heel and the outside of the foot. Sometimes this nerve gets injured and enlarges, or gets bound down in scar tissue. This may occur from a sprained ankle type injury, a direct blow to the area, or even ill-fitting shoes. Treatment again is to use anti-inflammatories or surgical correction.

Posterior Heel Pain
There are three main causes of pain in the back of the heel. One, a heel spur (Haglund's deformity or pump bump); two, bursitis; and three, Achilles Tendonitis or rupture.

The back of the heel can have an enlargement on it which is caused by a foot structure that puts too much pressure on the back of the heel. This pressure causes the bone to respond by trying to build itself up and make itself stronger, and enlargement or calcium deposit is the result. This enlargement then causes pressure on the back of the heel, especially where the heel counter of a shoe can press on it. It is commonly called a pump bump or Haglund's deformity. Sometimes wearing shoes is impossible. Fortunately, using a simple quarter-inch heel lift may be all that is necessary to provide dramatic relief. Steroid injections or surgical intervention are infrequently required.

Achilles Tendonitis is one of the most frequent yet most disabling conditions we see. It can pre sent its pain anywhere along the course of the tendon but is usually just above its attachment to the heel. Symptoms usually begin as a dull ache with some swelling around the tendon. It may be very tender to touch and there also may be a Rice Crispy type of feel when it is pressed on. It is not a condition to be taken lightly. There is a covering around the tendon that if too inflamed for too long a period of time can cause scar tissue. This scar tissue causes the tendon covering to adhere to the tendon itself and the tendon's gliding mechanism is lost. Steroid injections are normally not used in this area because of the potential weakening of the tendon fibers.

Achilles tendon ruptures can also occur but generally are not in the back of the heel but higher up.

On occasion, x-rays of the heel will reveal a spur where the Achilles tendon attaches to the back of the heel. This finding is usually incidental and is of no significance. On rare occasions, however, it is so large it causes pain and must be removed. As with other spurs, excessive pull by the Achilles tendon causes the bone to react and form a spur. I point this out because it is often termed "arthritis." Arthritis in general is an inflammation of a joint which may be associated with spur formation. The spurs we see are for the most part mechanically induced and are not arthritic.

Other Painful Heel Conditions
Several other conditions must be presented in our discussion.

Inflammation of the growth center of the heel in adolescence (calcaneal apophysitis) is common. It is most prevalent in active, adolescent boys between the ages of 8 and 13 years, and it is caused either by pressure from the Achilles tendon as it attaches to the heel or by biomechanical stress.

The child usually complains of pain in the back or bottom of the heel. It may be in one or both heels. It is usually worse with periods of exercise and feels better with rest. Treatment using heel cups or arch supports is usually effective. The problem goes away when the foot bone matures.

Fractures of the heel bone may occur typically because of a fall but may be spontaneous due to overuse. They are not always easy to diagnose. X-rays must be taken when there is a chief complaint of heel pain. If there is a fracture of the heel bone, it is imperative to assess the vital structures around the area because they too may be injured.

Not all heel pains are mechanically induced. Arthritic conditions such as rheumatoid or psoriatic arthritis may cause symptoms very similar to mechanical problems. Metabolic disorders such as gout and diabetes are also found in patients complaining of heel pain. Appropriate evaluation especially utilizing laboratory tests is mandatory. Conservative care is usually satisfactory in alleviating the discomfort in conjunction with treatment of the systemic disorder.

Conclusion
As can be seen from our discussion, there are many causes of heel pain. One article that I reviewed in my research of this subject listed over 75 different diagnoses. I have attempted to present the most commonly occurring heel conditions by their locations. This helps to systematically classify and simplify the myriad of possible causes. With al most all injuries that are mechanically induced and non-traumatic, it is my feeling that self-treatment is appropriate for perhaps two to three weeks. If the symptoms persist, it is wise to seek a professional opinion. This certainly applies to heel pain which we can see has many different causes.