Non Traumatic Heel Pain

Heel pain is a very common Orthopaedic problem. It varies from a simple discomfort around the heel on walking to excruciating pain leaving a person bedridden. The pain usually arises from two areas, either under the heel (plantar fasciitis) or just behind it (Achilles tendinitis). Most painful conditions are mild and disappear on their own with rest alone; however, sometimes the pain may persist.

Non Traumatic Heel Pain

Causes of heel pain

In most cases, heel pain has a mechanical cause as a result of repetitive stress on the heel. It is more common in obese individuals and those with diabetes and thyroid disorders.

Common causes are:

Below the heel - Plantar fasciitis and Calcaneal spur

Behind the heel - Achilles tendonosis and bursitis

Plantar fasciitis - It is an inflammation of the plantar fascia which is a strong bowstring-like ligament that runs from the calcaneum (heel bone) to the tip of the foot. The patient experiences pain under the heel especially in the morning and after a period of rest.

Calcaneal spur - It is a bony outgrowth of the heel bone that causes pressure on the plantar fascia and the heel pad and causes pain.

Heel bursitis - It is an inflammation of the bursa behind the heel. Pain is typically felt at the back of the heel. Sometimes it is associated with a swelling too. As the day progresses the pain usually gets worse.

Achilles tendonosis: It is a condition associated with the progressive degeneration of the Achilles tendon. Due to excessive stress, the tendon thickens, weakens and becomes painful. Sometimes it is associated with calcium deposits inside the tendon referred to calcific tendonosis.

Treatments for heel pain

Conservative:

Rest the affected heel and avoid walking and climbing stairs.

Ice the affected part to reduce the swelling and inflammation.

Footwear modification: MCR footwear, Shoes with silicon heel cups, heel raise footwear and arched support footwear are recommended according to the patient's need.

Drugs:

Pain medications (Non-steroidal anti-inflammatory drugs) help in reducing pain and inflammation.

Physiotherapy:

Ultrasound, Extracorporeal shock wave therapy, Achilles stretching exercises, intrinsic foot exercises.

Non Traumatic Heel Pain

Injection:

A localized steroid injection is sometimes administered in the inflamed area to reduce pain and inflammation and provide quick relief.

PRP injection:

Platelet rich plasma (PRP) injection is a recent advancement in treating these problems where platelets are extracted from the patient's blood and injected into the affected region. The success rates are promising.

Surgery:

It is the last resort and is advised only in patients who do not respond well to conservative treatment.

For Plantar Fasciitis: In patients not responding to the above treatment, surgical release of the fascia is advised. It can be done open or endoscopically.

Calcaneal spur: Excision of the spur is done to prevent pressure symptoms.

Achilles tendonosis/calcific tendonosis: Needling of the calcification or decompression of the tendon is done. If there is a bony growth causing pressure (Haglund hump) it is removed surgically.

Preventing heel pain

Prevention of heel pain involves reducing the stress on that part of the body. Tips include:

Barefeet - when on hard ground make sure you are wearing shoes.

Bodyweight - if you are overweight there is more stress on the heels when you walk or run. Try to lose weight.

Footwear - Footwear that has material which can absorb some of the stress placed on the heel may help protect it. Examples include heel pads. Make sure your shoes fit properly and do not wear worn down heels or soles. If you notice a link between a particular pair of shoes and heel pain, stop wearing them.

Sports - Warm up properly before engaging in activities that may place lots of stress on the heels. Make sure you have proper sports shoes for your task.

Article by Dr. M. Lakshmi Naathan, MS Orth, D Orth, MCh Orth
Consultant Orthopedician,
Kauvery Hospital, Chennai

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