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Heel Pain

Innovation Podiatry  >  Conditions  >  Heel Pain

Common heel pain conditions, symptoms and treatments are outlined below:

Plantar Heel Pain (click to open/close)
Overview

Often lumped under the term ‘plantar fasciitis’ or ‘heel spur’, plantar heel pain is very common and can be very disabling, especially those first few steps in the morning or when getting up from sitting. There are a number of differential diagnoses that need to be considered, for example calcaneal stress fracture, fat pad pathology, nerve irritation, abductor hallucis tendinopathy or plantar fascia pathology.

To help with diagnosis, we will conduct a thorough history, enabling us to:

  • Consider whether further investigations are warranted (i.e. if any red flags are raised). These may include imaging to exclude fractures and tears, or blood tests for inflammatory markers.
  • Determine causative factors – have you recently started a new training regime? Changed footwear? Had to lift or move heavy objects? Gained weight?
  • Assess for underlying biomechanical factors that may be increasing both compression and tensile forces on the plantar fascia.

To diagnose this condition and identify the painful structure and likely causative factors, we will conduct an in-depth assessment, including:

  • Thorough history
  • Strength and range of motion testing
  • Biomechanical and gait assessment
  • Evaluation of work, leisure activities and training programs that may exacerbate the condition
  • Evaluation of footwear
  • Referral for appropriate imaging (x-ray, ultrasound, MRI, CT etc.).
Treatment

We have a wide range of therapies in our ‘tool box’, depending on your individual situation. These may include:

  • Offloading in a moonboot if severe, or a fracture or tear is present
  • Taping (neurophysiological effect) to reduce pain and improve function
  • Stretching exercises – calf muscles and specific to the plantar fascia
  • Strengthening exercises for the small muscles in the feet
  • ESWT shockwave therapy
  • Footwear advice
  • Activity modification
  • Dry needling and western medical acupuncture.
  • Off-the-shelf or custom orthoses.
Tarsal Tunnel Syndrome
Overview

Tarsal tunnel syndrome is a chronic injury caused by compression or squeezing of the nerve that provides sensation to the bottom of your foot. This nerve is called the Posterior Tibial Nerve and passes through a fibrous tunnel located behind the bone on the inside of your ankle, known as the Tarsal Tunnel.

This nerve is very sensitive to pressure once it becomes compressed or squeezed and can cause a variety of sensations or feelings. Often times, the feeling of “pins and needles”, burning or numbness may be felt. Pain may be felt when the area behind the inside ankle bone is pressed. The feeling of pain and numbness may also be felt when running or standing for long periods of time or even wearing tight shoes. These painful feelings or sensations are often worse at night.

In addition to pain directly over the nerve, patients often experience pain, tingling, burning or other unusual sensations through the arch, around to the bottom of the foot or radiating to the toes.

To diagnose this condition and identify the painful structure and likely causative factors, we will conduct an in-depth assessment, including:

  • Thorough history
  • Strength and range of motion testing
  • Biomechanical and gait assessment
  • Evaluation of work, leisure activities and training programs that may exacerbate the condition
  • Evaluation of footwear
  • Referral for appropriate imaging (x-ray, ultrasound, MRI, CT etc.).
Treatment

This condition may be diagnosed by a careful history and physical examination by your podiatrist. They may touch the course of the nerve with a vibrating tuning fork, or tap the nerve gently with a rubber percussion hammer.

Rest and over-the-counter anti-inflammatory medication, like ibuprofen, may help calm the inflamed nerve. Over-the-counter shoe inserts may also help control any excessive motion of your foot that is contributing to the injury. If the cause is abnormal motion of the foot, custom moulded orthotics may be provided. Avoiding certain types of shoes that may be too tight or too flimsy may also help.

Your GP may give you prescription strength anti-inflammatory medication or a cortisone injection to provide relief. If all conservative treatments fail, then surgery may be recommended to release the Posterior Tibial Nerve.

Sever's Disease
Overview

Sever’s disease (Calcaneal apophysitis) is common in younger adolescents. A child may complain of pain around the heel, particularly the back of the heel, and may limp.

Calcaneal apophysitis occurs when the growth plate in the heel has not yet fused. It is therefore common in children between around 10-14 years of age (but can occur earlier), particularly after a growth spurt. It is thought that the calf muscles may apply too much traction at the unfused growth plate causing swelling and pain. Flat or high arched feet may also increase risk.

To diagnose this condition and identify the painful structure and likely causative factors, we will conduct an in-depth assessment, including:

  • Thorough history
  • Strength and range of motion testing
  • Biomechanical and gait assessment
  • Evaluation of work, leisure activities and training programs that may exacerbate the condition
  • Evaluation of footwear
  • Referral for appropriate imaging (x-ray, ultrasound, MRI, CT etc.).
Treatment

Fortunately, symptoms will settle when the growth plate fuses, typically around 14 years of age, although this varies from person to person.

Treatment modalities such as supportive cushioned footwear, stretches, strapping, heel lifts or orthotics may help.

Fat Pad Contusion

Overview

Your heel fat pad is a layer of thick tissue made up of dense fat pockets surrounded by touch but stretchy muscle fibers. When you walk, run, and jump, your fat pad acts as a shock absorber, distributing your body weight and protecting your bones and joints. Over time, this thick tissue wears down and too much wear and tear can cause the fat pad to lose its elasticity, and become less capable of absorbing shock. This is known as fat pad contusion or fat pad syndrome. When this happens, walking, standing, running and jumping can cause pain in one or both heels.

To diagnose this condition and identify the painful structure and likely causative factors, we will conduct an in-depth assessment, including:

  • Thorough history
  • Strength and range of motion testing
  • Biomechanical and gait assessment
  • Evaluation of work, leisure activities and training programs that may exacerbate the condition
  • Evaluation of footwear
  • Referral for appropriate imaging (x-ray, ultrasound, MRI, CT etc.).

Certain factors can contribute to the development of fat pad syndrome such as:

  • Aging. The aging process can cause heel pads to lose some elasticity.
  • Foot structure and gait. If your weight isn’t distributed evenly across your heel when you walk, parts of your heel pad might wear down more quickly over time.
  • Excess body weight. Carrying extra body weight puts additional stress on the heel pad. As a result, it may break down more quickly.
  • Plantar fasciitis. Plantar fasciitis makes it more difficult for your heel to absorb and distribute the impact associated with activities such as walking and running. As a result, the heel pad can deteriorate more quickly.
  • Repetitive activities. Any activity that involves the heel repeatedly striking the ground, like running, basketball, or gymnastics, can trigger inflammation leading to heel pad syndrome.
  • Hard surfaces. Frequently walking on hard surfaces can increase risk of heel pad syndrome.
  • Inappropriate footwear. Walking or running barefoot requires your heels to absorb more impact than they would in shoes.
  • Fat pad atrophy. Certain health conditions, including type 2 diabetes, lupus, and rheumatoid arthritis, can contribute to the shrinking of the heel pad.
  • Spurs. Heel spurs can reduce heel pad elasticity and contribute to heel pain.

Treatment

Whilst there is no cure for fat pad syndrome, the goal of treatments is to reduce the pain and inflammation associated with the condition with either one, or the following of treatments as per your podiatrist:

  • Rest. You can avoid heel pain by staying off your feet or limiting activities that cause heel pain.
  • Heel cups and orthotics. Heel cups are shoe inserts designed to provide heel support and cushioning. You can also find orthotic soles designed to provide extra heel support or cushioning. Heel cups and orthotics are available online and at most pharmacies.
  • Orthopedic footwear. Visit a podiatrist or a shoe store specializing in orthopedic footwear to find shoes with extra heel support.
  • Medication. Over-the-counter (OTC) or prescription anti-inflammatory or pain-relief medication can help alleviate pain caused by heel pad syndrome.
  • Ice. Ice may relieve pain and reduce inflammation. Apply an ice pack to your heel for 15- to 20-minute intervals after activities that trigger heel pain.
Charcot Neuroarthropathy of the Calcaneus

Overview

Click Here 

To diagnose this condition and identify the painful structure and likely causative factors, we will conduct an in-depth assessment, including:

  • Thorough history
  • Strength and range of motion testing
  • Biomechanical and gait assessment
  • Evaluation of work, leisure activities and training programs that may exacerbate the condition
  • Evaluation of footwear
  • Referral for appropriate imaging (x-ray, ultrasound, MRI, CT etc.).

Treatment

Click Here 

Baxter's Nerve Entrapment

Overview

What is Baxter’s nerve entrapment?  Heel pain is arguably the most common complaint a podiatrist hears. Though most of these complaints are linked to plantar fasciitis, it is important to recognise that there are numerous conditions that can cause heel pain. When plantar fasciitis does not respond to treatment, heel pain may, in fact, be associated with the entrapment of Baxter’s nerve. Baxter’s nerve entrapment results from compression of a nerve that supplies the plantar surface (underneath) of your foot. This nerve is also known as the inferior calcaneal nerve which snakes around the front of the heel bone. When this nerve is entrapped it can result in pain and numbness being experienced in the heel and bottom of the foot. According to Baxter, as much as 20% of heel pain is actually caused by entrapment of the inferior calcaneal nerve.

Signs and symptoms of Baxter’s nerve entrapment  The main reason why plantar fasciitis and Baxter’s nerve entrapment get confused is due to the similarity in the location of pain. In Baxter’s nerve entrapment, distinct tenderness is felt at the origin of the abductor hallucis muscle (a small muscle along the inside of the foot), whereas the most intense site of pain in plantar fasciitis is commonly more towards the bottom of the heel. Additionally, unlike plantar fasciitis, pain associated with entrapment tends to get worse with physical activity, rather than better. This is clinically known as post-kinetic dyskinesia. With entrapment, the pain is also more localised and is pressure sensitive. Consequently, in some cases, orthotic therapy may aggravate the pain if they have been prescribed to address a different diagnosis. This will be due to the orthotic further compressing the nerve. Other symptoms include burning and sharp shooting pain. Patients occasionally also locate the pain at the edges of the heel, either the outer or inner edge.

Causes of Baxter’s nerve entrapment There are two main causes of Baxter’s nerve entrapment: The first, and most common, is when the nerve becomes entrapped between two muscles, known as abductor hallucis muscle and the quadratus plantae muscle. These muscles are located along the lower aspect of the inside (medial-plantar) of the heel. The second is when the nerve becomes compressed against the heel bone on the under (plantar) side of the foot. Heel spurs (calcaneal plantar enthesophytes) and swelling of the plantar fascia may contribute to nerve entrapment at this location.

Risk factors for development of Baxter’s nerve entrapment include:

  • Over-pronation (flat feet)
  • Calcaneal spur
  • Obesity
  • Advancing age
  • Plantar fasciitis
  • Underlying mass
  • Vascular enlargement
  • Muscular enlargement (such as in athletes)

Diagnosing Baxter’s nerve entrapment 

Due to the complexity of the foot and symptoms that are often indistinguishable to plantar fasciitis, diagnosing Baxter’s nerve entrapment requires a high degree of clinical suspicion and knowledge. Comprehensive history taking and clinical examination should be performed to assess for possible nerve related symptoms. This is extremely important as there is no definitive test to diagnose Baxter’s nerve entrapment. X-ray, ultrasound and MRI can be used, but only to rule out other possible conditions and risk factors.

To diagnose this condition and identify the painful structure and likely causative factors, we will conduct an in-depth assessment, including:

  • Thorough history
  • Strength and range of motion testing
  • Biomechanical and gait assessment
  • Evaluation of work, leisure activities and training programs that may exacerbate the condition
  • Evaluation of footwear
  • Referral for appropriate imaging (x-ray, ultrasound, MRI, CT etc.).

Treatment

Conservative treatment aims to reduce the causative factors of entrapment. Treatment may include:

  • Activity modification. An initial change to your exercise regime or daily activities may be needed to avoid the condition getting worse. The introduction of a low impact alternate activity may also be of benefit such as swimming.
  • Icing: to reduce possible inflammation.
  • Strengthening/Isometric loading. It is important that strength is addressed for this condition so that the affected area can tolerate more load. This is done initially with isometric loading to load up the affected area in a pain-free way.
  • Massage: to help release excessive tight soft tissue structures that surround the nerve.
  • Taping/splinting: to control poor foot motion and function.
  • Orthotic therapy: can be used to address causative biomechanical factors such as flat feet, over-pronation.
  • Injection therapy: local anesthetic and corticosteroid can help bathe the nerve and reduce symptoms.

Some of the conservative treatment options are similar to those used for plantar fasciitis. However, with plantar fasciopathy pain levels tend to improve within weeks of a good treatment plan. In those that are non-responsive to conservative treatment, a diagnosis of Baxter’s nerve entrapment is further supported.

Surgery for Baxter’s nerve entrapment  Surgery is often indicated when pain levels fail to improve with conservative treatment. Additionally, if pain levels cease after an injection only for a short time before returning, surgery is also warranted. Surgery for Baxter’s nerve entrapment is known as neurolysis and may also be combined with a plantar fascia release.

Achilles Tendonitis/Tendinopathy

Overview

Achilles tendinopathy is pain affecting the Achilles tendon when it can’t tolerate a certain load being put through it. The condition can vary in severity from a mild pain in the tendon during a minor activity to more severe cases, where any form of physical activity that places strain on the structure, even standing or walking, can cause intense pain.

Symptoms usually include pain in the Achilles tendon, which is often worse after rest or with excessive activity. There can be local swelling when in an acute phase and thickening when in a chronic phase. It commonly occurs 2-3cm above the heel bone, but may also occur at the insertion of the Achilles tendon into the heel bone.

Achilles tendinopathy most commonly results from overuse, where the tendon is continuously  stressed until small tears occur. Sudden increases in physical activity is also a common cause, due to the tendon not being conditioned to withstand the increase physical stress. Other causative factors may include:

  • excessive pronation or flattening of the feet,
  • tight or weak calf muscles,
  • reduced ankle range of motion,
  • inappropriate or old footwear,
  • unbalanced muscle groups,
  • excessive sand or hill running,
  • poor biomechanics (the way you walk)

To diagnose this condition and identify the painful structure and likely causative factors, we will conduct an in-depth assessment, including:

  • Thorough history
  • Strength and range of motion testing
  • Biomechanical and gait assessment
  • Evaluation of work, leisure activities and training programs that may exacerbate the condition
  • Evaluation of footwear
  • Referral for appropriate imaging (x-ray, ultrasound, MRI, CT etc.).

Treatment

Because Achilles tendinopathy can quickly progress and reduce your ability to engage in activity, we recommend treatment as soon as possible. This will also reduce the chance of further complications. It is recommended that a Biomechanical Assessment be performed to get a detailed understanding of the condition specific to you. Once Biomechanical Assessment is complete, a tailored treatment plan will be developed. The type of treatment depends on the site of the pain, the duration of symptoms, foot function, footwear, and your current or intended activity levels. The aim of the treatment is to reduce strain on the tendon, reduce inflammation and strengthen the tendon so it can tolerate more load.

  • Activity modification. An initial change to your exercise regime or daily activities may be needed to avoid the condition getting worse. The introduction of a low impact alternate activity may also be of benefit such as swimming.
  • Strengthening/Isometric loading. It is important that calf strength is addressed for achilles pain so the tendon can tolerate more load. This is done initially with isometric loading to load up the tendon in a pain free way.
  • Increase in ankle range. Poor ankle range can be a common mechanism contributing to achilles pain, therefore intervention to increase ankle ROM will be implemented when necessary.
  • Heat or Ice.  This condition may respond better to either heat or ice depending if there is an acute flare up or chronic management.
  • Anti-inflammatory. Nonsteroidal anti-inflammatory drugs (NSAIDs), like ibuprofen, naproxen, or aspirin, will help with pain and swelling as per GP instructions.
  • Adequate footwear. Supportive and appropriate footwear is recommended to stabilise the foot and ankle. Avoid wearing thongs, slippers, sandals and barefoot.
  • Taping/Bracing. Taping or bracing can help to stabilise the foot and ankle and reduce excessive stress on the achilles.
  • Orthotic therapy: A custom orthotic device placed in the shoe can help address possible causative factors such as flat feet, to reduce stress on the achilles.
  • Extra Corporeal Shockwave Therapy. A non-invasive treatment where shockwaves are sent into the foot to stimulate the body’s own healing process.

In cases that are non-responsive to conservative treatment, surgical intervention may be required. For some advanced cases, surgery may be the only option.

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