| Heel pain is one of the most common painful conditions | | | | relieve inflammation. |
| seen in an arthritis clinic. This article discusses the | | | | A temporary reduction in activity is important in |
| various types of problems that cause heel pain and | | | | athletes, particularly runners. Cross training with |
| what can be done to make the situation better. | | | | swimming and cycling can help maintain cardiovascular |
| It's estimated that more than 1 million persons in the | | | | fitness while sparing the plantar fascia from pounding. |
| United States suffer from heel pain at any given time. | | | | Runners should avoid hills and make sure that any foot |
| When a patient complains of heel pain, it must be | | | | abnormality be corrected with custom orthotics. |
| clarified by history whether the pain is in the bottom of | | | | Ice massage with ice cubes applied to the plantar |
| the heel or the back of the heel because the diagnosis | | | | fascia can also be helpful. |
| and treatment are very different. | | | | Shoes with soft heels and inner soles can relieve |
| Pain in the bottom of the heel is often due to plantar | | | | discomfort. Rigid heel cups and arch supports are |
| fasciitis (PF). The plantar fascia is a tough band of | | | | generally not recommended. The patient may gradually |
| tissue that begins at the medial (inside) part of the | | | | resume normal activities over an eight week period of |
| bottom of the heel and extends forward to attach at | | | | time. Rushing rehabilitation is not advised. |
| the ball of the foot. The fascia is responsible for | | | | If there is no improvement, a night splint which holds |
| maintaining the normal arch. When an excessive load | | | | the ankle in 10 degrees of dorsiflexion prevents the |
| is placed on the fascia, pain can develop at the origin | | | | shortening of the plantar fascia. |
| (the heel) as well as the mid-portion (arch) of the | | | | If the night splint fails or the pain does not lessen, |
| fascia. | | | | injection of glucocorticoid (cortisone) using ultrasound |
| PF can develop in anyone but is more common in | | | | guidance is recommended. Injections should be limited |
| certain groups such as athletes, people older than 30 | | | | to a maximum of two given over four weeks. |
| years of age, and obese individuals. | | | | Patients who do not get better need to be |
| PF must be distinguished from other causes of bottom | | | | reevaluated for systemic disease or other conditions |
| of the heel pain such as nerve entrapment, atrophy of | | | | causing heel pain. |
| the normal heel fat pad, stress fracture of the | | | | Surgery is the last resort. Transverse release of the |
| calcaneus (heel bone), rupture of the plantar fascia, | | | | plantar fascia is the procedure of choice. This can be |
| bone cyst, bone tumor, and bone infection. | | | | done using arthroscopic guidance. |
| The history typically describes a gradual onset of | | | | Pain in the back of the heel is an entirely different |
| symptoms with no prior trauma. The most telling | | | | condition. |
| symptom is severe pain in the bottom of the heel | | | | The major structure here is the Achilles tendon which |
| when taking the first morning step. Patients may report | | | | extends down from the gastrocnemius muscle to |
| difficulty walking to the bath room. The pain tends to | | | | attach at the rear of the calcaneus. |
| lessen with more walking. This "first step" pain is also | | | | Inflammation of the Achilles tendon can occur, usually in |
| present during the day if the patient has been sitting | | | | athletes or in people in engage in overxuberant |
| for awhile, then getting up to walk. | | | | physical activity involving running or jumping. Patient |
| On exam, pain is noted with pressure applied to the | | | | who are overweight are also at risk. The pain is usually |
| medial bottom of the heel. Tenderness is worsened by | | | | described as a soreness. There is localized swelling |
| pointing the toes and ankle toward the head. This is | | | | and tenderness. Ultrasound can be used to |
| because the plantar fascia is being stretched. Pain in | | | | differentiate an inflamed Achilles tendon from one that |
| the arch may also be present. | | | | is partially or fully torn. The treatment involves |
| One in older patients should be ruled out and that is | | | | anti-inflammatory medicines, physical therapy, and |
| heel pad atrophy. Normally the heel has a thick feeling | | | | stretching exercises. Glucocorticoid injection is not |
| to it. In older patients the heel pad may lose this | | | | recommended because of the danger of weakening |
| thickness and flatten out. The pain is located more | | | | the Achilles tendon leading to rupture. Using a foam |
| centrally. | | | | rubber lift to elevate the heel in a shoe can help with |
| Another "fooler" is entrapment of the lateral plantar | | | | symptoms. |
| nerve. Pain is felt in the medial heel but may be | | | | Achilles rupture is handled surgically and requires a long |
| present at rest as well. There may be weakness | | | | recuperation. |
| spreading the toes. | | | | Haglund's syndrome, which is a condition where a spur |
| Fracture of the calcaneus (heelbone) causes pain at | | | | develops at the back of the calcaneus and is often |
| rest that is worsened with walking. Tenderness is | | | | associated with localized Achilles tendonitis can also |
| present along the sides of the heel. Magnetic | | | | cause pain in the back of the heel. Ill-fitting shoes are |
| resonance imaging (MRI) can confirm the presence if | | | | the most common cause. Typically a bump develops |
| fracture. | | | | at the back of the heel. Because of its association with |
| But what about "bone spurs"? The presence of a | | | | ill-fitting shoes, this is sometimes referred to as a |
| bone spur by itself means nothing. They are very | | | | "pump bump." Physical therapy, anti-inflammatory |
| common and by themselves are not a cause of pain. | | | | medicines, and stretching can often be of benefit. |
| Some patients with inflammatory forms of arthritis | | | | Glucocorticoid injection should be sparingly employed |
| such as psoriatic arthritis, ankylosing spondylitis, or | | | | because of the danger of Achilles rupture. Wearing |
| Reiter's disease have a specific type of spur that | | | | proper fitting shoes are an obvious adjunctive |
| should prompt further evaluation looking for systemic | | | | treatment. |
| forms of arthritis. | | | | Bursitis involving the retrocalcaneal bursa (the small |
| Diagnostic studies such as ultrasound and magnetic | | | | sack that lies between the Achilles tendon and the |
| resonance imaging can be used to confirm the | | | | calcaneus is a cause of pain behind the heel. |
| presence of plantar fasciitis. Electromyography (EMG) | | | | Treatment involves the use of physical therapy |
| may be needed to rule out lateral plantar nerve | | | | modalities such as ultrasound. Sometimes |
| entrapment. | | | | glucocorticoid injection may be needed. It is important |
| So how is this condition treated? | | | | to limit the injection to one because of the danger of |
| The first thing is to institute a stretching regimen. Most | | | | possible weakening of the Achilles tendon leading to |
| people with PF also have a shortened Achilles tendon | | | | rupture. Ultrasound needle guidance is advised to |
| and the ability to dorsiflex (point the toes up) is limited. | | | | ensure proper localization of the injection. |
| The plantar fascia is continuous with the Achilles | | | | The diagnosis is made by history and physical |
| fascia. Stretching the plantar fascia and the Achilles | | | | examination. Both MRI and ultrasound can be used for |
| decreases the tension in the plantar fascia and helps | | | | confirmation. |