The Diagnosis of Heel Pain

Heel pain is the most common type of foot pain, affecting more than 2 million people each year.  It is found at any age but most commonly between the ages of 8 to 80. Disability from heel pain can be temporary, lasting just a few days or long term and debilitating.
 
There are a lot of treatments for heel pain, ranging from conservative to very radical.  Some conservative measures include ice, rest, elevation, acupuncture, oral steroids, orthotic therapy, massage, acupressure, casts and strapping.  Radical care includes things like plantar fasciotomy, exostectomy, bursectomy, calcaneal osteotomy, lysis of adhesions, plantar fasciectomy, and tendon lengthening procedures.
 
Infections can be the cause of heel pain and systemic diseases, such as gout, rheumatoid arthritis, Reiter’s syndrome, psoriatic arthritis and ankylosing spondylitis can all have heel pain.  Pain just associated with the heel includes:
  • Heel spurs
  • Plantar fasciitis
  • Haglund deformity
  • Achilles tendinitis
  • Flexor hallucis longus tendinitis
  • Achilles tendon calcification
  • Tarsal tunnel syndrome
Plantar Fasciitis
 
Plantar fasciitis is the most common form of heel pain.  It is caused be repetitive stress rather than direct trauma to the heel.  Patients often have this for a long period of time before seeking medical attention.  An actual heel spur may or may not show up on x-ray.  Pain is revealed by pushing on the calcaneal tubercle or along the plantar fascia.  The plantar fascia is what helps maintain the arch of the foot and when it is inflamed, the arch can be flattened.  The treatment is usually conservative with stretching of the muscles and tendons; however, injections of steroids can be undertaken.
Plantar fasciitis can occur with high arches or low arches.  Depending on the degree of arch, an orthotic device can be used such as a heel lift that puts the pressure off the heel.  The foot can also be strapped to take pressure away from the fascia and onto the tendons, relieving pain.  Scar tissue can be removed by using deep tissue massage and fascial release therapy.
 
Heel Spurs

Heel spurs happen when there are micro-tears in the proximal plantar fascia.  The bone becomes irritated and builds up bone to become a spur.  X-rays will usually show an obvious bone spur. The presentation is much like with plantar fasciitis and the treatment is basically the same as well.
 
Haglund Deformity

This usually comes from wearing high heels too much.  It has symptoms similar to Achilles tendonitis.  The patient usually has a prominent posterosuperior part of the calcaneus.   The lateral x-ray will show the area of prominence.  There is a bulge in the posterior heel when the patient is standing.  The condition is usually healed with rest, NSAID therapy, removal of the heel counter and heel lifts that take the pressure off that part of the heel.  Surgery to include an osteotomy can be done in severe cases that don’t respond to conservative measures.
 
Achilles Tendon Calcification
 
This is a heel spur that occurs in the posterior part of the calcaneus, where the Achilles tendon attaches.  It can be found along with bursitis of the Achilles tendon.  A lateral x-ray will show whitening of the Achilles tendon.  Pain is dull and aching and is found at the insertion of the tendon.  This is a common type of pain as seen in dancers and some types of athletes.  There can be crepitation because of chronic inflammation of the Achilles tendon.
 
Conservative care can be undertaken which includes rest and stretching of the tendons.  Ice can relieve pain and swelling and surgery can be done which detaches the Achilles tendon and reattaches it to normal calcaneal bone.  With this kind of radical approach, there can be weakening of the gastrocnemius muscle, requiring physical therapy and strengthening.
 
Achilles Tendonitis
 
This involves an irritation of the tendon sheath surrounding the Achilles tendon or of the tendon itself.  It is usually caused by repetitive stress injuries to the Achilles tendon as seen in jumpers, dancers and other types of athletes.  Tenderness is usually found about three centimeters from the insertion of the tendon into the heel.  Treatment consists of athletes having longer warmup times, heel lifts, flexibility training, NSAIDs and cross-fiber massage.  Stretching is very important to healing this injury.
 
Tarsal Tunnel Syndrome

The tarsal tunnel is located on the medial aspect of the ankle.  There are four separate canals located in the tunnel that are formed by two different septa.  The canals carry the posterior tibial muscle, the flexor hallucis longus muscle, the posterior tibial nerve and the flexor digitorum longus muscle.  These structures can become trapped, yielding pain.  Patients often can’t precisely locate the pain but describe generalized pain along the inferior part of the medial malleolus.  Pain is of gradual onset and is described as a burning pain or an aching pain or an unremitting pain.  There can be paresthesias because of the nerve involvement.  Pain is present whether or not there is weight bearing.  Pain will radiate to the toes or to the calf and an electromyogram can be used to diagnose the condition.  It is often caused by having flat feet.  Arch support can be a good conservative way of managing the symptoms as can strapping the ankle.  Custom orthotics will also help.  In some cases, steroid injection can be used to relieve inflammation.

Flexor Hallucis Longus Tendinitis

This is usually caused by overuse of the flexor hallucis longus tendon with pain associated with the sole of the foot.  The pain isn’t associated with passive dorsiflexion but can run along the tendon with active dorsiflexion.  The tendon will stand out from the base of the great toe and up along the arch of the foot.  Most pain is associated at the proximal part of the tendon and is more superficial and distal to where the pain would be in heel spur syndrome.  The treatment is usually conservative, using soft-sole shoes, massage and a transverse arch band.  Steroid injection has been tried but it runs the risk of rupturing the tendon.  
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